Cognitive Behaviour
Therapy for Anxiety
Jodie Paget BSc Hons, PG Cert, PG Dip
Associate Tutor CBT Skills
CBT is…
An action orientated psychotherapy that
teaches individuals to identify, challenge,
and replace their self-defeating thoughts and
beliefs with healthier thoughts that promote
emotional well-being and goal achievement.
Men are disturbed not by things, but by
the view which they take of them -
Epictetus
CBT Model
The basic CBT model proposes that every
experience we have has specific thoughts
(beliefs), emotions, physiological responses
and behaviour associated with it.
You have been told you are losing your job
Scenario
How might you feel?
Angry, Anxious, Depressed…Happy?
What would you need to think (and believe)
about losing your job to feel each of the
above?
• How we feel emotionally gives us a very good insight
into what we are thinking and the ‘health’ of our thoughts.
• So feeling extreme anxiety accompanied by physical
discomfort (headaches, nausea, IBS etc…) would
suggest some ‘unhealthy’ thinking is occurring.
• Healthy beliefs result in healthy emotional and
behavioural responses.
What is Anxiety? CBT defines anxiety as an emotion, more specifically an unhealthy
emotion. Unhealthy emotions always result from unhealthy thinking and
most often produce maldaptive behaviour responses.
Thought Process
Overestimation of threat
Underestimation of ability to cope
Creates even more negative threat in ones mind
Has task irrelevant thoughts
Behaviours
Withdraw from threat (Physically or mentally)
To ward off the threat (by superstitious behaviour)
To seek reassurance
Healthy Concern rather than Anxiety
Overestimation of threat/danger
Anxiety= Underestimation of coping + rescue factors
Concern is viewed as a healthy emotion in that it is always associated with the
following:
Thoughts
Views threats realistically
Realistic appraisal of coping ability
Does not create an even more negative threat in ones mind
Has more task relevant thoughts than in anxiety
Behaviours
To face up to threat
To deal with threat constructively
Anxiety Disorders
There are many types of anxiety disorders – we are covering:
Panic Disorder
Social Anxiety Disorder
Health Anxiety
Safety Behaviour A behaviour engaged in that ‘prevents’ catastrophe from occurring
Panic Disorder
• A panic attack is an abrupt surge of
intense fear that reaches a peak within
minutes, during which time 4 or more of a
list of 13 symptoms occur.
• The attack appears to come ‘out of the
blue’
• 2%-3% in adults and adolescents
• Females out number males by 2:1
Panic Attack Criteria
• 1. Palpitations, pounding heart, or accelerated heart rate.
• 2. Sweating.
• 3. Trembling or shaking.
• 4. Sensations of shortness of breath or smothering.
• 5. Feelings of choking.
• 6. Chest pain or discomfort.
• 7. Nausea or abdominal distress.
• 8. Feeling dizzy, unsteady, light-headed, or faint.
• 9. Chills or heat sensations.
• 10. Paresthesias (numbness or tingling sensations).
• 11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
• 12. Fear of losing control or "going crazy."
• 13. Fear of dying.
The Cognitive Model of Panic Internal/External Trigger
Palpitation, shortness of breath
Perceived Threat
I can’t breathe, I might faint
ANXIETY
(Panic)
Physical/Cognitive Symptoms
My chest is getting tighter
My heart is racing – there is
something wrong with it
Pounding chest, dizziness, tunnel
vision, dry mouth
Catastrophic Misinterpretation
I’m going to die
I’m going to pass out and nobody
will help
Avoidance and Safety Behaviours
(What you did that prevented the catastrophe)
Left the situation
Never go out alone
Take unnecessary medication
Avoid exercising
Working with Panic Disorder
• Psychoeducation – physiology of anxiety, triggers, and the maintenance cycle
• Theory A vs. Theory B
• Panic Diaries
• Identifying (and dropping) safety behaviours
• Induction of anxiety symptoms
• Fear Hierarchy - Behaviour Experiments
• Relapse prevention
Social Anxiety Disorder
• Intense, fear of social situations in which the individual may be scrutinized by others (FNE).
• Concerned that he or she will be judged as anxious, weak, crazy, stupid, boring, intimidating, dirty, or unlikable etc.
• The individual fears that they will act or appear in a certain way or show anxiety symptoms (blushing, trembling, sweating etc) that will be negatively evaluated by others.
• The individual will often avoid the feared social situations or endure them with intense fear.
• Avoidance can be extensive (e.g., not going to parties, refusing school) or subtle (e.g., over preparing a speech, diverting attention to others, limiting eye contact).
The Cognitive Model of Social Anxiety Disorder Social Situation
Group Discussion
Activates Assumptions
I must not show signs of anxiety
I must appear competent
Perceived Social Danger
(Negative Automatic thoughts)
They think I am stupid
They think I’m anxious
Processing of Self
as Social Object
Self Conscious,
image as bright red,
is aware of own voice Safety Behaviours
Not participate
Sit at the back
Not make eye contact
Somatic and Cognitive
Symptoms
Trembling, racing heart, dry throat,
difficulty concentrating
Co
nta
min
ation
How CBT works with Social Anxiety Disorder
• Psychoeducation – The model, triggers
• Eliciting thoughts, and assumptions
• Eliciting safety behaviours and anxiety symptoms
• Disputing assumptions and challenging negative automatic thoughts (thinking errors)
• Behaviour experiments to test predictions
• Modifying self-processing in the moment (attentional training)
• Managing anticipatory anxiety (cognitive restructuring, distraction)
• Managing the ‘post mortem’ (Assess the pros and cons of the post mortem, it’s
distorted nature then finally banning it)
Health Anxiety (Illness Anxiety Disorder)
formerly Hypochondriasis
• Preoccupation with having or getting a serious medical illness
• Checkups often do not detect any medical problems however despite this the individual's anxiety comes from not the illness itself but rather the meaning and/or significance of the illness.
• If a symptom is present, it is often a normal sensation (e.g. dizziness), or a bodily discomfort not generally considered indicative of disease (e.g., belching).
• If a diagnosable condition is present, the anxiety and preoccupation are excessive and disproportionate to the severity of the condition
• Two Types of behaviour:
• Care Seeking and Care avoidant
The Cognitive Model of Health Anxiety
Negative Automatic Thoughts
There is something terribly wrong with me, I must know
what’s wrong, I can’t bear not knowing
Anxiety Behaviour
Reassurance seeking
Visiting the doctor
Checking the internet
Scanning for symptoms
Avoidance
Cognitive
Focusing on symptoms
Discounting medical feedback
Overemphasising the
significance of symptoms
Physiological Changes
Increased arousal
Trigger
Death of a friend/family member
How CBT works with Health Anxiety
• Explore evidence for disease fears
• Assess avoidance and safety behaviours
• Managing selective attention
• Explore alternative evidence for disease and develop alternative
explanation for symptoms (Theory A and Theory B)
• Behaviour experiments to challenge misinterpretations (drop safety
behaviours, avoidance, checking etc)
• Fear Hierarchy (exposure)
• Explore the role of reassurance seeking – eventually dropping it
• Introduce rational responding to thoughts
Summary What is the danger? Appraise this realistically
How will I cope with it, what are my rescue factors?
– How have I coped with similar situations?
– What are my transferable strengths?
– Engage in a problem solving mindset rather that circular worry
– Dispute your anxiety generating beliefs and develop balanced coping
beliefs, practice behaving in accordance with these beliefs
If you can behave productively DO IT!
- Problem solving, generate three solutions, assess them accordingly
- if this isn’t possible use distraction (an activity that heavily engages your
mind or your body
Develop a list of distraction methods/activities that work for you
If symptoms persist practice tolerating them, challenge your belief that
they are UNBEARABLE
Questions