Behavioral Interventions for Anxiety Disorders Dr. Maite P. Mena
Cognitive Behavior Therapy (CBT) has been found tobe an efficacious treatment for anxiety disordersincluding: GAD PTSD OCD
Beck’s negative cognitive triad Negative view of self I’m no good I’m useless I’m inadequate Negative view of the Negative view of the world futureMy problems are insurmountable It will always be this wayPeople are cruel I will never get betterEverything is very difficult Things will never work out for me
CBT is based on the cognitive model, which states thatpeople’s emotions, behaviors, and physical reactionsare influenced by how they perceive events. Theprinciples of CBT are: 1)Formulate problem in cognitive terms: -What aspects of client’s current thinking acts to maintain problematic emotions and behaviors? -Therapist might also be concerned with precipitating factors (context)- what environmental events might have influenced perceptions -Therapist would also be interested in developing hypotheses about key developmental events and enduring patterns of interpreting these events.
CBT Principles2) Therapy requires a good therapeutic alliance-warmth, caring, genuine regard Listening closely Empathizing Accurately summarize thoughts and emotions
CBT Principles3) Collaboration and active participation--Encourage client to view therapy as teamwork-Assign work between sessions-Over time, give client more responsibility to direct session.
CBT Principles4) Cognitive Therapy is goal-oriented and problem- focused Client encouraged in initial session to develop a problem list Set specific goals of a behavioral nature-lonely- develop new friendships-develop plan, set HW Identify thoughts interfering with goals
Principles-CBT5) Present focused- here-and-now emphasis first (want to reduce symptom stress).Attention shifts to past when: a) client expresses strong desire, b) work on present problems produces little change in cognitions, emotions, behaviors, c) important dysfunctional ideas developed in the past (If I always do well, I am ok, if I don’t do well I am not ok)
Principles-CBT6) Cognitive therapists aim to educate the person so that they can be their own therapist (self-help) using the techniques learned in therapy.7) Therapy is intended to be time-limited (4-14 sessions) however this is not always possible.8) CBT is structured.
CBT-Principles9) Cognitive therapy teaches clients to identify, evaluate, and respond to their dysfunctional thoughts and beliefs The most basic question is to ask, ―What was going through your mind when _____?‖ Then evaluate the validity of the thought via Socratic Questioning-Where is it written that what you told yourself is true, and even if it were true, is it really as bad as you tell yourself? CBT uses collaborative empiricism- helping determine accuracy of a thought.
CBT-Principles10) Cognitive therapy use a variety of techniques to change thinking, mood and behavior. Emphasis in treatment also depends on disorder client is presenting with.
CBT Therapist enters ―collaborative‖ relationship with client. The therapy is very structured and the session follows an agenda starting with review of homework and ending with a summary.
CBT Therapist needs to focus on systematic errors in reasoning and restructure. Negative automatic thoughts disrupt one’s mood. Leads to spiraling down. Distorted reasoning based on systematic logical errors. Therapy is an active process (eliciting self- talk/interpretations, gathering evidence against interpretation, setting up homework)
Automatic Thoughts A spontaneously arising verbal or visual content of consciousness with symbolic representation. Automatic thoughts are brief and patients are often more aware of the emotion they feel as a result of their thoughts than of the thoughts themselves.
Negative Automatic Thoughts Short, specific thoughts which often do not occur in sentences, but may consist of a few key words, images or memories Spontaneous and often extremely rapid Not the result of deliberation or reasoning Associated with negative emotional reactions Generally appear reasonable at the time but usually involve more distortion of reality than other types of thinking
Identifying and challenging cognitivedistortions First step is to identify negative beliefs. Write descriptions of situations where they experienced disturbing emotions. Document their emotions as these will give a clue as to the likely cognitive distortion underlying their difficult emotions. Write down negative thoughts.
Identifying and Categorizing CoreBeliefs (the therapist) Mentally hypothesize where core belief specific automatic thoughts came from Specify the core belief Present hypothesis about the core belief to the patient Educate patient about core beliefs in general and about their core beliefs Help patient specify and strengthen a new more adaptive core belief Begin to evaluate and modify negative core beliefs with patient
Cognitive Restructuring CBT holds that most of our emotions and behaviors are the result of what we think or believe about ourselves, other people, and the world. These cognitions shape how we interpret and evaluate what happens to us, influence how we feel about it, and provide a guide to how we should respond. Sometimes our interpretations, evaluations, and underlying beliefs thoughts contain distortions, errors, or biases, or are not very useful or helpful. Cognitive restructuring is a set of techniques for becoming more aware of our thoughts and for modifying them when they are distorted or are not useful. This approach does not involve distorting reality in a positive direction or attempting to believe the unbelievable. Rather, it uses reason and evidence to replace distorted thought patterns with more accurate, believable, and functional ones.
The term ―cognitive distortion‖ refers to errors in thinking or patterns of thought that are biased in some way. They may include: (A) interpretations that are not very accurate and which selectively filter the available evidence, (B) evaluations that are harsh and unfair, and/or (C) expectations for oneself and for others that are rigid and unreasonable. The more a person’s thinking is characterized by these distortions, the more they are likely to experience disturbing emotions and to engage in maladaptive behavior.
Some examples of common patterns of cognitive distortionsare: All-or-nothing thinking: Looking at things in absolute, black-and-white categories, instead of on a continuum. For example, if something is less than perfect, one sees it as a total failure. Overgeneralization: Viewing a negative event as a part of a never-ending pattern of negativity while ignoring evidence to the contrary. Using words such as never, always, all, every, none, no one, nobody, or everyone. Mental filter: Focusing on a single negative detail and dwelling it on it exclusively until one’s vision of reality becomes darkened. Magnification or minimization (e.g., magnifying the negative and minimizing the positive): Exaggerating the importance of one’s problems and shortcomings. A form of this is called ―catastrophizing‖ in which one tells oneself that an undesirable situation is unbearable, when it is really just uncomfortable or inconvenient.
Mind reading: Concluding what someone is thinking without any evidence, not considering other possibilities, and making no effort to check it out. Emotional reasoning: Assuming that one’s negative emotions necessarily reflect the way things really are (e.g., ―Because I feel it, it must be true.‖ ―I feel stupid, therefore I am stupid‖). Rigid rules (perfectionism). Having a precise, fixed idea of how oneself or others should behave, and overestimating how bad it is when these expectations are not met. Often phrased as "should" or ―must‖ statements. Unfair judgments: Holding oneself personally responsible for events that arent (or aren’t entirely) under one’s control, or blaming other people and overlooking ways in which one might have also contributed to the problem.
In CBT: The therapist guides the client through the process of becoming more aware of what they are telling themselves and helps them to evaluate, and when appropriate, to modify their own thinking. The therapist teaches the client a process that will help them distinguish distorted thinking from more accurate and useful thinking. The therapist does not assume that the client’s thoughts are distorted and instead attempts to guide the client with questions that encourage the client to make their own discoveries. Clients are also encouraged to practice this process on their own between sessions (homework).
CBT Homework Homework is integral to CBT and the goal is to extend the opportunities for cognitive and behavioral change throughout the patient’s week. Tailor the assignment to the individual Provide sound rationale Uncover potential obstacles Modify relevant beliefs
Systematic desensitization Developed by Joseph Wolpe in 1950s Patient creates hierarchy of 20-30 items of ascending fearfulness Deep muscle relaxation practiced while imagining each scene repeatedly until it could be imagined without anxiety. Pairing of opposite emotional experiences (relaxation with anxiety-provoking stimuli) termed reciprocal inhibition.
Systematic Desensitization Systematic desensitization is a therapeutic intervention that reduces the learned link between anxiety and objects or situations that are typically fear-producing. The aim of systematic desensitization is to reduce or eliminate fears or phobias that sufferers find are distressing or that impair their ability to manage daily life. By substituting a new response to a feared situation, a trained contradictory response of relaxation which is irreconcilable with an anxious response — phobic reactions are diminished or eradicated.
Exposure therapy Developed by Marks, Gelder & Rachman in the late 60s and 70s. Good results using graded exposure in vivo for phobias and OCD. Flooding is exposure to feared stimulus at maximal intensity until anxiety habituates – rapid & effective but very distressing for the patient.
Exposure Therapy Exposure is an important behavioral technique in the treatment of anxiety disorders. Assumption is that anxiety is maintained by avoidance of the feared stimuli.Exposure to the feared stimuli: Challenges the belief that there are negative consequences by coming into contact with the stimuli Allows physiological ―habituation.‖
Exposure to what? Posttraumatic Stress Disorder- expose to traumatic st memories (1 ) and avoided places, people, activities nd (2 ). Obsessive Compulsive Disorder- expose to obsessive thoughts and triggers of compulsions with avoidance of compulsive behavior (response prevention). Generalized Anxiety Disorder- expose to worries
Exposure therapy Graded Hierarchy – patient controlled and directed ―Anxiety is unpleasant but does no harm.‖ As real as possible (imagination < in vivo) , to produce the greatest level of discomfort and anxiety that the patient is willing to experience Without internal or external distraction Until anxiety goes away or is reduced by at least 50%. ―Anxiety eventually reduces.‖ As frequent as possible ―practice makes perfect.‖
Types of Exposure In session exposure (imagined) In vivo exposure
In session exposure Patients imagine themselves coming into contact with the feared stimuli. Described coming into contact with the feared stimuli onto a tape recorder with their eyes closed. Re-expose themselves to this recording.
In session exposure is used when: Exposure to live situations is too anxiety generating for the patient to tolerate. Live exposure is impractical. Exposure is not immediately available. The queues are not external but are internal e.g. memories.
In vivo exposure: This is the best form of exposure and should be used wherever possible. Patients can normally initiate their own exposure Initially this may be modelled by the therapist to assist this process. Once initiated in a clinical setting the patient is encouraged to repeat this as frequently as possible outside the therapy sessions.
Steps in conducting exposure Preparation. Creation of exposure hierarchy. Initial exposure. Repeated exposure.
Preparation for conducting exposure Explain treatment rationale. Explore advantages and perceived disadvantages of doing exposure. Obtain, inform, consent and commitment to carrying out exposure. Explain that: Anxiety is unpleasant and does no harm Anxiety eventually reduces Practice makes perfect
Creation of exposure hierarchy The patient should describe all cues that evoke anxiety (alternatively describe the things they avoid) and create a list Rate each item on a 0-100% scale 0 being no discomfort/anxiety 100 being maximum discomfort/anxiety Can rate in imaginable contact Use rating to rank list
Initial Exposure Graded exposure involves graduated exposure beginning with the item that produces least discomfort/anxiety and working up the scale. Habituation can take hours and sessions should be structured accordingly (initial exposure continued while another patient is being seen before the session may be continued). The patient should rate their anxiety/discomfort on a 0-100 scale every five minutes and exposure continued until anxiety has reduced by at least 50%.
Repeated Exposure This should be continued on at least a daily basis Record each event as exposure is carried out. The patient moves up the hierarchy as they feel able.
Relaxation techniques:Goals in relaxation A coping mechanism to help patients gain a sense of mastery over their internal world Aim is to facilitate engagement with activities of everyday living and exposure tasks. Not an intrinsic therapeutic activity.
Different types of relaxationProgressive muscle Breathing relaxation. relaxation. Cue controlled relaxation.12 muscle group relaxation. Holding the breath.8 muscle group relaxation. Rhythmic breathing.4 muscle group relaxation. Counting breaths.Release only relaxation.
Relaxation method Take a comfortable position Using fixed narrative Encouraged to breath gently Tense the area to the count of three breaths and then release slowly to the count of five Pause for 15 to 20 seconds Progressing to the next muscle group. At end counting down five to one visualising relaxation. Repeated using tape recorder.
12 muscle group relaxationThese are: Shoulders. Lower arms. Back of the neck. Upper arms. Lips. Lower legs. Eyes. Thighs. Eye brows. Stomach. Upper forehead and Upper chest and back. scalp.
8 muscle group relaxation 1. Whole arms. 2. Whole legs. 3. Stomach. 4. Upper chest and back. 5. Shoulders. 6. Back of the neck. 7. Face. 8. Forehead and scalp.
4 muscle group relaxation 1. Whole arms. 2. Upper chest and back. 3. Shoulders and neck. 4. Face.
Relaxation key points Focus on the physical sensation of tension and to gain mastery over this. Use diaphragmatic breathing rather than light chest breathing which can lead to hyper- ventilation. These breaths can be timed to the count of three.
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