cbt for anxiety2
TRANSCRIPT
CBT Based CBT Based Anxiety Anxiety
ManagementManagementDr Farooq Naeem
Cognitive Behaviour Cognitive Behaviour TherapyTherapy
Behaviour therapyBehaviour therapy
Classical conditioning Classical conditioning
operant conditioningoperant conditioning Cognitive therapyCognitive therapy
emotions are due to our perception emotions are due to our perception of events of events
emotional problems due to faulty emotional problems due to faulty thinkingthinking
Does not focus very much on the pastDoes not focus very much on the past Therapist and client are equal Therapist and client are equal Effective inEffective in
DepressionDepression
Anxiety Disorders Panic Phobias Anxiety Disorders Panic Phobias
SchizophreniaSchizophrenia
And many other psychiatric problemsAnd many other psychiatric problems
BasicsBasics Link between thoughts emotions Link between thoughts emotions
amp behaviour amp behaviour Automatic thoughts Automatic thoughts Cognitive errors Cognitive errors Cognitive triad Cognitive triad beliefs about self others and the beliefs about self others and the
worldworld assumptions and beliefs assumptions and beliefs
Antecedents
Cognitions
Emotions Behaviours
Physical symptoms
Thinking distortions (negative Thinking distortions (negative automatic thoughts)automatic thoughts) Jumping to conclusionsJumping to conclusions Selective abstractionSelective abstraction OvergeneralisationOvergeneralisation Magnification or minimisationMagnification or minimisation PersonalisationPersonalisation All or nothing thinking All or nothing thinking
Important considerationsImportant considerations
FormatFormatGroupGroup
IndividualIndividual
Family involvement Family involvement Itrsquos a self help therapyItrsquos a self help therapy Therapist issuesTherapist issues Patient issuesPatient issues
Versions Versions 11
ManualisedManualised
Formulation based Formulation based 22
Cognitive behaviour therapyCognitive behaviour therapy
CBT based treatmentCBT based treatment
Self help Self help
Anxiety Anxiety
Prevalence Prevalence
6 throughout the world6 throughout the world higher in Pakistan higher in Pakistan
no study on prevalence in general no study on prevalence in general population population
Women 57 (74 non-working 36 Women 57 (74 non-working 36 working women)working women)
General hospital (GAD 56 General hospital (GAD 56 depression depression 24 and panic disorders 20) 24 and panic disorders 20)
Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles
85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60
Co morbidity Co morbidity Depression Depression
Schizophrenia Schizophrenia
Personality disrodersPersonality disroders
Organic disorders Organic disorders
Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression
What is anxietyWhat is anxiety
Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety
Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders
generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)
panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)
post traumatic stress disorderpost traumatic stress disorder
obsessive compulsive disorderobsessive compulsive disorder
specific phobia (eg of spiders)specific phobia (eg of spiders)
social phobia (social anxiety disorder)social phobia (social anxiety disorder)
acute stress disorderacute stress disorder
Situational anxiety Situational anxiety
Stress factorsStress factors
ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder
A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or
accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or
dehydration)dehydration)
Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg
churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-
headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization
(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out
(12) Fear of dying(12) Fear of dying
General symptomsGeneral symptoms
(13) Hot flushes or cold chills(13) Hot flushes or cold chills
(14) Numbness or tingling sensations(14) Numbness or tingling sensations
Symptoms of tensionSymptoms of tension
(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax(16) Restlessness and inability to relax
(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension
(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing
Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or
being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going
blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of
worrying worrying
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Cognitive Behaviour Cognitive Behaviour TherapyTherapy
Behaviour therapyBehaviour therapy
Classical conditioning Classical conditioning
operant conditioningoperant conditioning Cognitive therapyCognitive therapy
emotions are due to our perception emotions are due to our perception of events of events
emotional problems due to faulty emotional problems due to faulty thinkingthinking
Does not focus very much on the pastDoes not focus very much on the past Therapist and client are equal Therapist and client are equal Effective inEffective in
DepressionDepression
Anxiety Disorders Panic Phobias Anxiety Disorders Panic Phobias
SchizophreniaSchizophrenia
And many other psychiatric problemsAnd many other psychiatric problems
BasicsBasics Link between thoughts emotions Link between thoughts emotions
amp behaviour amp behaviour Automatic thoughts Automatic thoughts Cognitive errors Cognitive errors Cognitive triad Cognitive triad beliefs about self others and the beliefs about self others and the
worldworld assumptions and beliefs assumptions and beliefs
Antecedents
Cognitions
Emotions Behaviours
Physical symptoms
Thinking distortions (negative Thinking distortions (negative automatic thoughts)automatic thoughts) Jumping to conclusionsJumping to conclusions Selective abstractionSelective abstraction OvergeneralisationOvergeneralisation Magnification or minimisationMagnification or minimisation PersonalisationPersonalisation All or nothing thinking All or nothing thinking
Important considerationsImportant considerations
FormatFormatGroupGroup
IndividualIndividual
Family involvement Family involvement Itrsquos a self help therapyItrsquos a self help therapy Therapist issuesTherapist issues Patient issuesPatient issues
Versions Versions 11
ManualisedManualised
Formulation based Formulation based 22
Cognitive behaviour therapyCognitive behaviour therapy
CBT based treatmentCBT based treatment
Self help Self help
Anxiety Anxiety
Prevalence Prevalence
6 throughout the world6 throughout the world higher in Pakistan higher in Pakistan
no study on prevalence in general no study on prevalence in general population population
Women 57 (74 non-working 36 Women 57 (74 non-working 36 working women)working women)
General hospital (GAD 56 General hospital (GAD 56 depression depression 24 and panic disorders 20) 24 and panic disorders 20)
Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles
85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60
Co morbidity Co morbidity Depression Depression
Schizophrenia Schizophrenia
Personality disrodersPersonality disroders
Organic disorders Organic disorders
Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression
What is anxietyWhat is anxiety
Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety
Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders
generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)
panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)
post traumatic stress disorderpost traumatic stress disorder
obsessive compulsive disorderobsessive compulsive disorder
specific phobia (eg of spiders)specific phobia (eg of spiders)
social phobia (social anxiety disorder)social phobia (social anxiety disorder)
acute stress disorderacute stress disorder
Situational anxiety Situational anxiety
Stress factorsStress factors
ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder
A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or
accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or
dehydration)dehydration)
Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg
churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-
headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization
(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out
(12) Fear of dying(12) Fear of dying
General symptomsGeneral symptoms
(13) Hot flushes or cold chills(13) Hot flushes or cold chills
(14) Numbness or tingling sensations(14) Numbness or tingling sensations
Symptoms of tensionSymptoms of tension
(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax(16) Restlessness and inability to relax
(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension
(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing
Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or
being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going
blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of
worrying worrying
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Does not focus very much on the pastDoes not focus very much on the past Therapist and client are equal Therapist and client are equal Effective inEffective in
DepressionDepression
Anxiety Disorders Panic Phobias Anxiety Disorders Panic Phobias
SchizophreniaSchizophrenia
And many other psychiatric problemsAnd many other psychiatric problems
BasicsBasics Link between thoughts emotions Link between thoughts emotions
amp behaviour amp behaviour Automatic thoughts Automatic thoughts Cognitive errors Cognitive errors Cognitive triad Cognitive triad beliefs about self others and the beliefs about self others and the
worldworld assumptions and beliefs assumptions and beliefs
Antecedents
Cognitions
Emotions Behaviours
Physical symptoms
Thinking distortions (negative Thinking distortions (negative automatic thoughts)automatic thoughts) Jumping to conclusionsJumping to conclusions Selective abstractionSelective abstraction OvergeneralisationOvergeneralisation Magnification or minimisationMagnification or minimisation PersonalisationPersonalisation All or nothing thinking All or nothing thinking
Important considerationsImportant considerations
FormatFormatGroupGroup
IndividualIndividual
Family involvement Family involvement Itrsquos a self help therapyItrsquos a self help therapy Therapist issuesTherapist issues Patient issuesPatient issues
Versions Versions 11
ManualisedManualised
Formulation based Formulation based 22
Cognitive behaviour therapyCognitive behaviour therapy
CBT based treatmentCBT based treatment
Self help Self help
Anxiety Anxiety
Prevalence Prevalence
6 throughout the world6 throughout the world higher in Pakistan higher in Pakistan
no study on prevalence in general no study on prevalence in general population population
Women 57 (74 non-working 36 Women 57 (74 non-working 36 working women)working women)
General hospital (GAD 56 General hospital (GAD 56 depression depression 24 and panic disorders 20) 24 and panic disorders 20)
Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles
85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60
Co morbidity Co morbidity Depression Depression
Schizophrenia Schizophrenia
Personality disrodersPersonality disroders
Organic disorders Organic disorders
Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression
What is anxietyWhat is anxiety
Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety
Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders
generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)
panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)
post traumatic stress disorderpost traumatic stress disorder
obsessive compulsive disorderobsessive compulsive disorder
specific phobia (eg of spiders)specific phobia (eg of spiders)
social phobia (social anxiety disorder)social phobia (social anxiety disorder)
acute stress disorderacute stress disorder
Situational anxiety Situational anxiety
Stress factorsStress factors
ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder
A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or
accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or
dehydration)dehydration)
Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg
churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-
headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization
(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out
(12) Fear of dying(12) Fear of dying
General symptomsGeneral symptoms
(13) Hot flushes or cold chills(13) Hot flushes or cold chills
(14) Numbness or tingling sensations(14) Numbness or tingling sensations
Symptoms of tensionSymptoms of tension
(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax(16) Restlessness and inability to relax
(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension
(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing
Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or
being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going
blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of
worrying worrying
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
BasicsBasics Link between thoughts emotions Link between thoughts emotions
amp behaviour amp behaviour Automatic thoughts Automatic thoughts Cognitive errors Cognitive errors Cognitive triad Cognitive triad beliefs about self others and the beliefs about self others and the
worldworld assumptions and beliefs assumptions and beliefs
Antecedents
Cognitions
Emotions Behaviours
Physical symptoms
Thinking distortions (negative Thinking distortions (negative automatic thoughts)automatic thoughts) Jumping to conclusionsJumping to conclusions Selective abstractionSelective abstraction OvergeneralisationOvergeneralisation Magnification or minimisationMagnification or minimisation PersonalisationPersonalisation All or nothing thinking All or nothing thinking
Important considerationsImportant considerations
FormatFormatGroupGroup
IndividualIndividual
Family involvement Family involvement Itrsquos a self help therapyItrsquos a self help therapy Therapist issuesTherapist issues Patient issuesPatient issues
Versions Versions 11
ManualisedManualised
Formulation based Formulation based 22
Cognitive behaviour therapyCognitive behaviour therapy
CBT based treatmentCBT based treatment
Self help Self help
Anxiety Anxiety
Prevalence Prevalence
6 throughout the world6 throughout the world higher in Pakistan higher in Pakistan
no study on prevalence in general no study on prevalence in general population population
Women 57 (74 non-working 36 Women 57 (74 non-working 36 working women)working women)
General hospital (GAD 56 General hospital (GAD 56 depression depression 24 and panic disorders 20) 24 and panic disorders 20)
Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles
85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60
Co morbidity Co morbidity Depression Depression
Schizophrenia Schizophrenia
Personality disrodersPersonality disroders
Organic disorders Organic disorders
Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression
What is anxietyWhat is anxiety
Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety
Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders
generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)
panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)
post traumatic stress disorderpost traumatic stress disorder
obsessive compulsive disorderobsessive compulsive disorder
specific phobia (eg of spiders)specific phobia (eg of spiders)
social phobia (social anxiety disorder)social phobia (social anxiety disorder)
acute stress disorderacute stress disorder
Situational anxiety Situational anxiety
Stress factorsStress factors
ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder
A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or
accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or
dehydration)dehydration)
Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg
churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-
headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization
(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out
(12) Fear of dying(12) Fear of dying
General symptomsGeneral symptoms
(13) Hot flushes or cold chills(13) Hot flushes or cold chills
(14) Numbness or tingling sensations(14) Numbness or tingling sensations
Symptoms of tensionSymptoms of tension
(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax(16) Restlessness and inability to relax
(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension
(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing
Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or
being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going
blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of
worrying worrying
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Antecedents
Cognitions
Emotions Behaviours
Physical symptoms
Thinking distortions (negative Thinking distortions (negative automatic thoughts)automatic thoughts) Jumping to conclusionsJumping to conclusions Selective abstractionSelective abstraction OvergeneralisationOvergeneralisation Magnification or minimisationMagnification or minimisation PersonalisationPersonalisation All or nothing thinking All or nothing thinking
Important considerationsImportant considerations
FormatFormatGroupGroup
IndividualIndividual
Family involvement Family involvement Itrsquos a self help therapyItrsquos a self help therapy Therapist issuesTherapist issues Patient issuesPatient issues
Versions Versions 11
ManualisedManualised
Formulation based Formulation based 22
Cognitive behaviour therapyCognitive behaviour therapy
CBT based treatmentCBT based treatment
Self help Self help
Anxiety Anxiety
Prevalence Prevalence
6 throughout the world6 throughout the world higher in Pakistan higher in Pakistan
no study on prevalence in general no study on prevalence in general population population
Women 57 (74 non-working 36 Women 57 (74 non-working 36 working women)working women)
General hospital (GAD 56 General hospital (GAD 56 depression depression 24 and panic disorders 20) 24 and panic disorders 20)
Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles
85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60
Co morbidity Co morbidity Depression Depression
Schizophrenia Schizophrenia
Personality disrodersPersonality disroders
Organic disorders Organic disorders
Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression
What is anxietyWhat is anxiety
Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety
Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders
generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)
panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)
post traumatic stress disorderpost traumatic stress disorder
obsessive compulsive disorderobsessive compulsive disorder
specific phobia (eg of spiders)specific phobia (eg of spiders)
social phobia (social anxiety disorder)social phobia (social anxiety disorder)
acute stress disorderacute stress disorder
Situational anxiety Situational anxiety
Stress factorsStress factors
ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder
A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or
accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or
dehydration)dehydration)
Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg
churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-
headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization
(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out
(12) Fear of dying(12) Fear of dying
General symptomsGeneral symptoms
(13) Hot flushes or cold chills(13) Hot flushes or cold chills
(14) Numbness or tingling sensations(14) Numbness or tingling sensations
Symptoms of tensionSymptoms of tension
(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax(16) Restlessness and inability to relax
(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension
(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing
Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or
being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going
blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of
worrying worrying
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Thinking distortions (negative Thinking distortions (negative automatic thoughts)automatic thoughts) Jumping to conclusionsJumping to conclusions Selective abstractionSelective abstraction OvergeneralisationOvergeneralisation Magnification or minimisationMagnification or minimisation PersonalisationPersonalisation All or nothing thinking All or nothing thinking
Important considerationsImportant considerations
FormatFormatGroupGroup
IndividualIndividual
Family involvement Family involvement Itrsquos a self help therapyItrsquos a self help therapy Therapist issuesTherapist issues Patient issuesPatient issues
Versions Versions 11
ManualisedManualised
Formulation based Formulation based 22
Cognitive behaviour therapyCognitive behaviour therapy
CBT based treatmentCBT based treatment
Self help Self help
Anxiety Anxiety
Prevalence Prevalence
6 throughout the world6 throughout the world higher in Pakistan higher in Pakistan
no study on prevalence in general no study on prevalence in general population population
Women 57 (74 non-working 36 Women 57 (74 non-working 36 working women)working women)
General hospital (GAD 56 General hospital (GAD 56 depression depression 24 and panic disorders 20) 24 and panic disorders 20)
Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles
85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60
Co morbidity Co morbidity Depression Depression
Schizophrenia Schizophrenia
Personality disrodersPersonality disroders
Organic disorders Organic disorders
Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression
What is anxietyWhat is anxiety
Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety
Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders
generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)
panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)
post traumatic stress disorderpost traumatic stress disorder
obsessive compulsive disorderobsessive compulsive disorder
specific phobia (eg of spiders)specific phobia (eg of spiders)
social phobia (social anxiety disorder)social phobia (social anxiety disorder)
acute stress disorderacute stress disorder
Situational anxiety Situational anxiety
Stress factorsStress factors
ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder
A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or
accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or
dehydration)dehydration)
Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg
churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-
headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization
(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out
(12) Fear of dying(12) Fear of dying
General symptomsGeneral symptoms
(13) Hot flushes or cold chills(13) Hot flushes or cold chills
(14) Numbness or tingling sensations(14) Numbness or tingling sensations
Symptoms of tensionSymptoms of tension
(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax(16) Restlessness and inability to relax
(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension
(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing
Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or
being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going
blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of
worrying worrying
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Important considerationsImportant considerations
FormatFormatGroupGroup
IndividualIndividual
Family involvement Family involvement Itrsquos a self help therapyItrsquos a self help therapy Therapist issuesTherapist issues Patient issuesPatient issues
Versions Versions 11
ManualisedManualised
Formulation based Formulation based 22
Cognitive behaviour therapyCognitive behaviour therapy
CBT based treatmentCBT based treatment
Self help Self help
Anxiety Anxiety
Prevalence Prevalence
6 throughout the world6 throughout the world higher in Pakistan higher in Pakistan
no study on prevalence in general no study on prevalence in general population population
Women 57 (74 non-working 36 Women 57 (74 non-working 36 working women)working women)
General hospital (GAD 56 General hospital (GAD 56 depression depression 24 and panic disorders 20) 24 and panic disorders 20)
Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles
85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60
Co morbidity Co morbidity Depression Depression
Schizophrenia Schizophrenia
Personality disrodersPersonality disroders
Organic disorders Organic disorders
Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression
What is anxietyWhat is anxiety
Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety
Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders
generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)
panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)
post traumatic stress disorderpost traumatic stress disorder
obsessive compulsive disorderobsessive compulsive disorder
specific phobia (eg of spiders)specific phobia (eg of spiders)
social phobia (social anxiety disorder)social phobia (social anxiety disorder)
acute stress disorderacute stress disorder
Situational anxiety Situational anxiety
Stress factorsStress factors
ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder
A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or
accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or
dehydration)dehydration)
Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg
churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-
headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization
(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out
(12) Fear of dying(12) Fear of dying
General symptomsGeneral symptoms
(13) Hot flushes or cold chills(13) Hot flushes or cold chills
(14) Numbness or tingling sensations(14) Numbness or tingling sensations
Symptoms of tensionSymptoms of tension
(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax(16) Restlessness and inability to relax
(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension
(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing
Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or
being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going
blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of
worrying worrying
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Versions Versions 11
ManualisedManualised
Formulation based Formulation based 22
Cognitive behaviour therapyCognitive behaviour therapy
CBT based treatmentCBT based treatment
Self help Self help
Anxiety Anxiety
Prevalence Prevalence
6 throughout the world6 throughout the world higher in Pakistan higher in Pakistan
no study on prevalence in general no study on prevalence in general population population
Women 57 (74 non-working 36 Women 57 (74 non-working 36 working women)working women)
General hospital (GAD 56 General hospital (GAD 56 depression depression 24 and panic disorders 20) 24 and panic disorders 20)
Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles
85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60
Co morbidity Co morbidity Depression Depression
Schizophrenia Schizophrenia
Personality disrodersPersonality disroders
Organic disorders Organic disorders
Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression
What is anxietyWhat is anxiety
Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety
Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders
generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)
panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)
post traumatic stress disorderpost traumatic stress disorder
obsessive compulsive disorderobsessive compulsive disorder
specific phobia (eg of spiders)specific phobia (eg of spiders)
social phobia (social anxiety disorder)social phobia (social anxiety disorder)
acute stress disorderacute stress disorder
Situational anxiety Situational anxiety
Stress factorsStress factors
ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder
A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or
accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or
dehydration)dehydration)
Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg
churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-
headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization
(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out
(12) Fear of dying(12) Fear of dying
General symptomsGeneral symptoms
(13) Hot flushes or cold chills(13) Hot flushes or cold chills
(14) Numbness or tingling sensations(14) Numbness or tingling sensations
Symptoms of tensionSymptoms of tension
(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax(16) Restlessness and inability to relax
(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension
(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing
Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or
being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going
blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of
worrying worrying
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Anxiety Anxiety
Prevalence Prevalence
6 throughout the world6 throughout the world higher in Pakistan higher in Pakistan
no study on prevalence in general no study on prevalence in general population population
Women 57 (74 non-working 36 Women 57 (74 non-working 36 working women)working women)
General hospital (GAD 56 General hospital (GAD 56 depression depression 24 and panic disorders 20) 24 and panic disorders 20)
Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles
85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60
Co morbidity Co morbidity Depression Depression
Schizophrenia Schizophrenia
Personality disrodersPersonality disroders
Organic disorders Organic disorders
Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression
What is anxietyWhat is anxiety
Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety
Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders
generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)
panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)
post traumatic stress disorderpost traumatic stress disorder
obsessive compulsive disorderobsessive compulsive disorder
specific phobia (eg of spiders)specific phobia (eg of spiders)
social phobia (social anxiety disorder)social phobia (social anxiety disorder)
acute stress disorderacute stress disorder
Situational anxiety Situational anxiety
Stress factorsStress factors
ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder
A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or
accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or
dehydration)dehydration)
Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg
churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-
headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization
(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out
(12) Fear of dying(12) Fear of dying
General symptomsGeneral symptoms
(13) Hot flushes or cold chills(13) Hot flushes or cold chills
(14) Numbness or tingling sensations(14) Numbness or tingling sensations
Symptoms of tensionSymptoms of tension
(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax(16) Restlessness and inability to relax
(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension
(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing
Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or
being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going
blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of
worrying worrying
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles
85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60
Co morbidity Co morbidity Depression Depression
Schizophrenia Schizophrenia
Personality disrodersPersonality disroders
Organic disorders Organic disorders
Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression
What is anxietyWhat is anxiety
Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety
Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders
generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)
panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)
post traumatic stress disorderpost traumatic stress disorder
obsessive compulsive disorderobsessive compulsive disorder
specific phobia (eg of spiders)specific phobia (eg of spiders)
social phobia (social anxiety disorder)social phobia (social anxiety disorder)
acute stress disorderacute stress disorder
Situational anxiety Situational anxiety
Stress factorsStress factors
ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder
A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or
accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or
dehydration)dehydration)
Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg
churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-
headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization
(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out
(12) Fear of dying(12) Fear of dying
General symptomsGeneral symptoms
(13) Hot flushes or cold chills(13) Hot flushes or cold chills
(14) Numbness or tingling sensations(14) Numbness or tingling sensations
Symptoms of tensionSymptoms of tension
(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax(16) Restlessness and inability to relax
(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension
(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing
Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or
being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going
blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of
worrying worrying
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Co morbidity Co morbidity Depression Depression
Schizophrenia Schizophrenia
Personality disrodersPersonality disroders
Organic disorders Organic disorders
Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression
What is anxietyWhat is anxiety
Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety
Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders
generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)
panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)
post traumatic stress disorderpost traumatic stress disorder
obsessive compulsive disorderobsessive compulsive disorder
specific phobia (eg of spiders)specific phobia (eg of spiders)
social phobia (social anxiety disorder)social phobia (social anxiety disorder)
acute stress disorderacute stress disorder
Situational anxiety Situational anxiety
Stress factorsStress factors
ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder
A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or
accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or
dehydration)dehydration)
Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg
churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-
headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization
(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out
(12) Fear of dying(12) Fear of dying
General symptomsGeneral symptoms
(13) Hot flushes or cold chills(13) Hot flushes or cold chills
(14) Numbness or tingling sensations(14) Numbness or tingling sensations
Symptoms of tensionSymptoms of tension
(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax(16) Restlessness and inability to relax
(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension
(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing
Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or
being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going
blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of
worrying worrying
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression
What is anxietyWhat is anxiety
Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety
Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders
generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)
panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)
post traumatic stress disorderpost traumatic stress disorder
obsessive compulsive disorderobsessive compulsive disorder
specific phobia (eg of spiders)specific phobia (eg of spiders)
social phobia (social anxiety disorder)social phobia (social anxiety disorder)
acute stress disorderacute stress disorder
Situational anxiety Situational anxiety
Stress factorsStress factors
ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder
A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or
accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or
dehydration)dehydration)
Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg
churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-
headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization
(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out
(12) Fear of dying(12) Fear of dying
General symptomsGeneral symptoms
(13) Hot flushes or cold chills(13) Hot flushes or cold chills
(14) Numbness or tingling sensations(14) Numbness or tingling sensations
Symptoms of tensionSymptoms of tension
(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax(16) Restlessness and inability to relax
(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension
(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing
Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or
being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going
blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of
worrying worrying
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
What is anxietyWhat is anxiety
Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety
Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders
generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)
panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)
post traumatic stress disorderpost traumatic stress disorder
obsessive compulsive disorderobsessive compulsive disorder
specific phobia (eg of spiders)specific phobia (eg of spiders)
social phobia (social anxiety disorder)social phobia (social anxiety disorder)
acute stress disorderacute stress disorder
Situational anxiety Situational anxiety
Stress factorsStress factors
ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder
A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or
accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or
dehydration)dehydration)
Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg
churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-
headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization
(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out
(12) Fear of dying(12) Fear of dying
General symptomsGeneral symptoms
(13) Hot flushes or cold chills(13) Hot flushes or cold chills
(14) Numbness or tingling sensations(14) Numbness or tingling sensations
Symptoms of tensionSymptoms of tension
(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax(16) Restlessness and inability to relax
(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension
(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing
Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or
being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going
blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of
worrying worrying
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
post traumatic stress disorderpost traumatic stress disorder
obsessive compulsive disorderobsessive compulsive disorder
specific phobia (eg of spiders)specific phobia (eg of spiders)
social phobia (social anxiety disorder)social phobia (social anxiety disorder)
acute stress disorderacute stress disorder
Situational anxiety Situational anxiety
Stress factorsStress factors
ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder
A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or
accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or
dehydration)dehydration)
Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg
churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-
headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization
(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out
(12) Fear of dying(12) Fear of dying
General symptomsGeneral symptoms
(13) Hot flushes or cold chills(13) Hot flushes or cold chills
(14) Numbness or tingling sensations(14) Numbness or tingling sensations
Symptoms of tensionSymptoms of tension
(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax(16) Restlessness and inability to relax
(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension
(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing
Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or
being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going
blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of
worrying worrying
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder
A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or
accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or
dehydration)dehydration)
Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg
churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-
headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization
(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out
(12) Fear of dying(12) Fear of dying
General symptomsGeneral symptoms
(13) Hot flushes or cold chills(13) Hot flushes or cold chills
(14) Numbness or tingling sensations(14) Numbness or tingling sensations
Symptoms of tensionSymptoms of tension
(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax(16) Restlessness and inability to relax
(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension
(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing
Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or
being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going
blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of
worrying worrying
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg
churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-
headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization
(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out
(12) Fear of dying(12) Fear of dying
General symptomsGeneral symptoms
(13) Hot flushes or cold chills(13) Hot flushes or cold chills
(14) Numbness or tingling sensations(14) Numbness or tingling sensations
Symptoms of tensionSymptoms of tension
(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax(16) Restlessness and inability to relax
(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension
(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing
Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or
being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going
blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of
worrying worrying
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out
(12) Fear of dying(12) Fear of dying
General symptomsGeneral symptoms
(13) Hot flushes or cold chills(13) Hot flushes or cold chills
(14) Numbness or tingling sensations(14) Numbness or tingling sensations
Symptoms of tensionSymptoms of tension
(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax(16) Restlessness and inability to relax
(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension
(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing
Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or
being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going
blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of
worrying worrying
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension
(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing
Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or
being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going
blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of
worrying worrying
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)
obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)
D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an
organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption
of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)
UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4
weeks (B)
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
3 Longer-term care of individuals 3 Longer-term care of individuals
Evidence based Interventions in descending Evidence based Interventions in descending orderorder
1048714 1048714 psychological therapy (A)psychological therapy (A)
1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)
1048714 1048714 self-help (A)self-help (A)
4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)
5 positive advantages of services based in primary 5 positive advantages of services based in primary care care
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Psychological interventionsPsychological interventions
6 CBT should be used (A)6 CBT should be used (A)
7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols
8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months
10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)
11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated
(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is
demonstrated demonstrated
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
15 An SSRI should be offered (B)15 An SSRI should be offered (B)
16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI
17 Consider the following17 Consider the following
1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly
1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)
1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some
1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Self-help interventionsSelf-help interventions
25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)
26 Information about support groups if 26 Information about support groups if available available
27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)
28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)
29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
RecommendationsRecommendations
1 CBT should be used (A)1 CBT should be used (A)
2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)
3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains
4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)
5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)
7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)
8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Research evidence (summary)Research evidence (summary)
Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)
2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)
3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
CBT in Pak Intial CBT in Pak Intial findingsfindings
Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists
REBT backgroundREBT background Diagnosesproblems Diagnosesproblems
Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)
Family conflicts bereavement otherFamily conflicts bereavement other
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic
Poor follow up Poor follow up Distance and moneyDistance and money
Female genderFemale gender
Low social status and lack of education Low social status and lack of education
Pills oriented and not psychological Pills oriented and not psychological mindedminded
What about role of faith healersWhat about role of faith healers
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about
therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are
symptoms freesymptoms free Process of therapy Process of therapy
Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Therapy ingredients Therapy ingredients Supportive therapySupportive therapy
Psycho educationPsycho education
PsychotherapyPsychotherapy
Family workFamily work Common techniquesCommon techniques
cognitive errors teachingcognitive errors teaching
cognitive restructuring cognitive restructuring
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Problem solvingProblem solving
Social skillsSocial skills
Assertiveness trainingAssertiveness training
Monitoring moodMonitoring mood
Communication skillsCommunication skills
Work on irrational beliefsWork on irrational beliefs
Behavioural methodsBehavioural methods
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles
Coping statements (amp prompt cards)Coping statements (amp prompt cards)
Biblio therapyBiblio therapy
Cultural context Cultural context
patients think its gupshup patients think its gupshup One single message from each session One single message from each session
Use of imagery Use of imagery
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Repeat shorter gapsRepeat shorter gaps
RapportRapport
Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy
instructional not collaborativeinstructional not collaborative
authoritative not authoritarianauthoritative not authoritarian
giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Causes of anxiety disordersCauses of anxiety disorders
Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances
overprotective parentsoverprotective parents
over critical parentsover critical parents
emotional insecurity and dependenceemotional insecurity and dependence
controlling parents controlling parents
parents who make child feel guilty or parents who make child feel guilty or ashamedashamed
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
parental neglect (emotional)parental neglect (emotional)
parental abuse parental abuse
cumulative stress over timecumulative stress over time
childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)
other illnesses insecuritiesother illnesses insecurities
other problems which cause low self other problems which cause low self esteemesteem
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness
drug or alcohol abuse drug or alcohol abuse
psychological causespsychological causes
stress ongoing or acutestress ongoing or acute
trauma trauma
personalitypersonality
another psychiatric conditionanother psychiatric condition
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
underlying beliefsunderlying beliefs
ongoing stressesongoing stresses
lack of assertivenesslack of assertiveness
lack of self nurturing skillslack of self nurturing skills
muscle tension or other bodily muscle tension or other bodily symptomssymptoms
stimulants and dietry factorsstimulants and dietry factors
high stress lifestylehigh stress lifestyle
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings
Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma
maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if
situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other
stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative
hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Post concussion syndromePost concussion syndrome
Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12
EmphysemaEmphysema
Pulmonary embolismPulmonary embolism
Cardiac arrythmiasCardiac arrythmias
Congestive heart failureCongestive heart failure
Essential hypertensionEssential hypertension
Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Sharing your understanding with Sharing your understanding with the patient the patient
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Assessment Assessment
Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth
empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical
systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too
detailed)detailed) Body language Body language
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Use of scalesUse of scales
Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression
scalescale Bradford somatic inventoryBradford somatic inventory
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Comprehensive Comprehensive management management
Physiological levelPhysiological levelPsycho education support Psycho education support
reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation
Emotional level Emotional level Suppressed feelingsSuppressed feelings
Learning to express your feelingsLearning to express your feelings
Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Behavioural level Behavioural level activity schedulingactivity scheduling
aerobic exercises aerobic exercises
eliminate avoidance behaviours eliminate avoidance behaviours
address problem behavioursaddress problem behaviours
problem solving problem solving
coping techniques coping techniques
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive
errors)errors)
dealing with cognitive errorsdealing with cognitive errors
dealing with underlying beliefsdealing with underlying beliefs
anger shame and guiltanger shame and guilt
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Interpersonal levelInterpersonal levelConflict managementConflict management
Communication skillsCommunication skills
Assertiveness Assertiveness
How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person
Time management Time management
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
whole self levelwhole self levelLow self esteemLow self esteem
Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Relaxations exercises Relaxations exercises
Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system
overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce
anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp
thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Breathing amp muscle Breathing amp muscle relaxation relaxation
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Principles of time Principles of time management management
PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and
overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Distraction techniquesDistraction techniques
Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your
surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count
wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Self talkSelf talk
worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure
ororcatastrophecatastrophe
the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as
better better ignores your positive qualititesignores your positive qualitites
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless
always complains about things always complains about things
something wrong with you (deprived something wrong with you (deprived defective or defective or
unworthy) unworthy)
need for approval and agreement from othersneed for approval and agreement from others
dependence on others (emotional physicaldependence on others (emotional physical
psychological)psychological)
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough
you should work even harderyou should work even harder
you should always have things under your you should always have things under your controlcontrol
people are either good or bad nothing in people are either good or bad nothing in betweenbetween
should always make people happyshould always make people happy
should always succeedshould always succeed
should always be humble should always be humble
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
How to deal with these self How to deal with these self talkstalks
What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements
avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Downward arrow techniqueDownward arrow technique
Socratic dialogue Socratic dialogue
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
What is your coping styleWhat is your coping style
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Coping (strategies) with Coping (strategies) with stressstress
physical strategiesphysical strategies
relaxationrelaxation
dietdiet
exerciseexercise
taking breakstaking breaks
time managemengenttime managemengent
sleep hygienssleep hygiens
environmentenvironment
material securitymaterial security
Emotional strategiesEmotional strategies
social support and social support and relatednessrelatedness
self nurturingself nurturing
assertivenessassertiveness
good communicationgood communication
assertivenessassertiveness
recreational activitiesrecreational activities
emotional releasseemotional releasse
sense of humoursense of humour
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Cognitive Cognitive strategiesstrategies
flexible constructive flexible constructive and alternative and alternative thinkingthinking
distractiondistraction
task oriented (vs task oriented (vs reactive)reactive)
Positive Self talkPositive Self talk
spiritualspiritual
acceptance and acceptance and forgivenessforgiveness
tolerance amp patience tolerance amp patience
trust in others trust in others
faith in good outcome faith in good outcome of future of future
purpose of life and purpose of life and workwork
religiousspiritual lifereligiousspiritual life
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Communication amp Communication amp conflictsconflicts
Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague
statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular
behaviourbehaviour Avoid generalistation Avoid generalistation
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Assertiveness tipsAssertiveness tips
StylesStylesPassivePassive
AggressiveAggressive
ManipulativeManipulative
AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
PrinciplesPrinciplesExpress your feelingsExpress your feelings
Ask for what you want (specific)Ask for what you want (specific)
Say no to something you donrsquot wantSay no to something you donrsquot want
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Tips on assertivenessTips on assertiveness
Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person
Body language (eg crossing arms etc)Body language (eg crossing arms etc)
Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)
Stay calm Stay calm Know their human rights and assert Know their human rights and assert
themthem Read on basic human rights Read on basic human rights
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want
Know your feelingsKnow your feelings
What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan
Speicify the situation and your reponseSpeicify the situation and your reponse
Specific clear concise Specific clear concise not long vague storynot long vague story
Write or prepare a statement Write or prepare a statement
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
developing a response developing a response evaluate your rights evaluate your rights
decide on a time and placedecide on a time and place
address the main person(s) address the main person(s)
state the problems in terms of specific relation state the problems in terms of specific relation with youwith you
express your feelings (I statments)express your feelings (I statments)
suggest an alternative(s) suggest an alternative(s)
talk about specific (realistic) consequences talk about specific (realistic) consequences
start with less threatening or less authoritarian start with less threatening or less authoritarian personperson
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Practising assertion role playPractising assertion role play
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by
repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think
about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
role playing real liferole playing real life
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Nutrition and parhezNutrition and parhez
Foods that aggravate Foods that aggravate anxietyanxiety
Caffeine Nicotine Caffeine Nicotine alcoholalcohol
Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and
animlas fed on animlas fed on hormoneshormones
Eating habitsEating habitsEating quickly Eating quickly
(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20
mouthfuls)mouthfuls)Eating too muc Eating too muc
Drinking too much Drinking too much fluid during mealfluid during meal
Sugar and Sugar and hypoglycaemiahypoglycaemia
Food allergy Food allergy
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Good diet for reducing Good diet for reducing anxietyanxiety
Eat more vegetables Eat more vegetables and fruitsand fruits
More raw vegetables More raw vegetables Careful with what Careful with what
you eatyou eat Stop eating refined Stop eating refined
and processed foodsand processed foods Stop food that causes Stop food that causes
allergy stomach or allergy stomach or other discomfortother discomfort
Less red meatLess red meat Increase dietry Increase dietry
fibrefibre Drink plenty of Drink plenty of
waterwater less fat and less fat and
carbohydratescarbohydrates
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins
Calcium and magnesium supplementsCalcium and magnesium supplements
Relaxing herbRelaxing herb
KavaKava
ValerianValerian
St johns wortSt johns wort
PassionflowerPassionflower
Gotu kolaGotu kola
Ginkgo bilobaGinkgo biloba
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Problems solving Problems solving approachapproach
Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change
(2) specific (2) specific
(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable
Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution
choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution
now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible
execute your planexecute your plan
review your outcomereview your outcome
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Practice problem solvingPractice problem solving
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Identifying and expressing Identifying and expressing feelingsfeelings
Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness
Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
What are the common types of What are the common types of emotions emotions
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Common types of emotions Common types of emotions
DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited
FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing
Mindfulness Mindfulness
Ask yourselfAsk yourself
Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)
Wait and listenWait and listen
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations
you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a
big explosionsbig explosions you have been caught while stealing you have been caught while stealing
from a shopfrom a shop your friend has told you off for no your friend has told you off for no
reasonsreasons you have been offered a jobyou have been offered a job
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Dealing with cognitive Dealing with cognitive errorserrors
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Teaching on thoughts Teaching on thoughts
What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from
emotionsemotions Negative automatic thoughtsNegative automatic thoughts
They are automaticThey are automatic - -
They are unhelpful -They are unhelpful -
They are believable - They are believable -
They are persistent They are persistent
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions
Selective abstractionSelective abstraction
OvergeneralisationOvergeneralisation
Magnification or minimisationMagnification or minimisation
PersonalisationPersonalisation
All or nothing thinkingAll or nothing thinking
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
How to discover thoughtsHow to discover thoughts
Exploring cognitive errors Exploring cognitive errors
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Thought diariesThought diaries
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Situation What Who When Where
Mood Feeling sensations
Thoughts(Words images or memories)
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Situation What Who
When Where
Mood Feeling
sensations
NegativeAutomaticthoughts
EvidenceThatSupportsThe thoughts
Evidencethat doesNotSupporttheThought
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Situation What WhoWhenWhere
Mood Feeling sensations
NegativeAutomaticthoughts
EvidencethatSupportsthethoughts
Evidencethat doesnotsupporttheThought
AlternativeThought(s)
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a
similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past
ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did
youyouthink thenthink then
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs
Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions
Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs