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  • 1. CBT Based Anxiety Management Dr Farooq Naeem
  • 2. Cognitive Behaviour Therapy
    • Behaviour therapy
    • Classical conditioning
    • operant conditioning
    • Cognitive therapy
    • emotions are due to our perception of events
    • emotional problems due to faulty thinking
  • 3.
    • Does not focus very much on the past
    • Therapist and client are equal?
    • Effective in
    • Depression
    • Anxiety Disorders, Panic, Phobias
    • Schizophrenia
    • And many other psychiatric problems
  • 4.
    • Basics
    • Link between thoughts, emotions & behaviour
    • Automatic thoughts
    • Cognitive errors
    • Cognitive triad
    • beliefs about self, others and the world
    • assumptions and beliefs
  • 5. Antecedents Cognitions Emotions Behaviours Physical symptoms
  • 6. Thinking distortions (negative automatic thoughts)
    • Jumping to conclusions .
    • Selective abstraction
    • Overgeneralisation
    • Magnification or minimisation
    • Personalisation
    • All or nothing thinking
  • 7. Important considerations
    • Format
      • Group
      • Individual
      • Family involvement
    • It’s a self help therapy
    • Therapist issues
    • Patient issues
  • 8.
    • Versions
    • 1
      • Manualised
      • Formulation based
    • 2
      • Cognitive behaviour therapy
      • CBT based treatment
      • Self help
  • 9. Anxiety
    • Prevalence
    • 6% throughout the world
    • higher in Pakistan
    • no study on prevalence in general population
    • Women 57% (74% non-working, 36% working women)
    • General hospital (GAD 56%, depression 24% and panic disorders 20%)
  • 10.
    • Somatic complaints
    • generalized headache 70%
    • pain neck and upper trunk muscles 85%
    • backache 52%
    • palpitation 45%
    • chest pain 25%
    • dyspepsia 60%
  • 11.
    • Co morbidity
      • Depression
      • Schizophrenia
      • Personality disroders
      • Organic disorders
  • 12.
    • Nearly 70% of patients in outpatient clinics in Pakistan present with a mixture of anxiety and depression
  • 13. What is anxiety?
    • Types of anxiety
      • Generalised anxiety
      • Specific, fears, phobias and panic attacks
    • Anxiety disorders
      • generalised anxiety disorder (GAD)
      • panic disorder (with or without agoraphobia)
  • 14.
      • post traumatic stress disorder
      • obsessive compulsive disorder
      • specific phobia (e.g. of spiders)
      • social phobia (social anxiety disorder)
      • acute stress disorder
      • Situational anxiety
      • Stress factors
  • 15. ICD 10 (R&DC) F41.1 Generalized Anxiety Disorder
    • A. Period of at least six months
    • B. At least four of these symptoms
    • at least one from items
    • (1) to (4).
    • Autonomic arousal symptoms
    • (1) Palpitations or pounding heart, or accelerated heart rate.
    • (2) Sweating.
    • (3) Trembling or shaking.
    • (4) Dry mouth (not due to medication or dehydration).
  • 16.
    • Symptoms concerning chest and abdomen
    • (5) Difficulty breathing.
    • (6) Feeling of choking.
    • (7) Chest pain or discomfort.
    • (8) Nausea or abdominal distress (e.g. churning in stomach).
    • Symptoms concerning brain and mind
    • (9) Feeling dizzy, unsteady, faint or light-headed.
    • (10) Derealization or depersonalization.
  • 17.
    • (11) Fear of losing control, going crazy, or passing out.
    • (12) Fear of dying.
    • General symptoms
    • (13) Hot flushes or cold chills.
    • (14) Numbness or tingling sensations
    • Symptoms of tension
    • (15) Muscle tension or aches and pains.
    • (16) Restlessness and inability to relax.
  • 18.
    • (17) Feeling keyed up, or on edge, or of mental tension.
    • (18) A sensation of a lump in the throat, or difficulty with swallowing.
    • Other non-specific symptoms
    • (19) Exaggerated response to minor surprises or being startled.
    • (20) Difficulty in concentrating, or mind going blank, because of worrying or anxiety.
    • (21) Persistent irritability.
    • (22) Difficulty getting to sleep because of worrying.
  • 19.
    • C. The disorder does not meet the criteria for panic disorder (F41.0), phobic anxiety disorders (F40.-),
    • obsessive-compulsive disorder (F42.-) or hypochondriacal disorder (F45.2).
    • D. Most commonly used exclusion criteria: not sustained by a physical disorder, such as hyperthyroidism, an
    • organic mental disorder (F0) or psychoactive substance-related disorder (F1), such as excess consumption
    • of amphetamine-like substances, or withdrawal from benzodiazepines.
  • 20. National institute of clinical excellence (NICE) UK guidelines
    • Generalised anxiety disorder
    • 1. Immediate management
    • 􀂊 support and information (D)
    • 􀂊 problem solving (C)
    • 􀂊 benzodiazepines (A)
    • 􀂊 sedating antihistamines (A)
    • 􀂊 self help (D)
    • 2. Benzodiazepines not beyond 2-4 weeks. (B)
  • 21.
    • 3. Longer-term care of individuals
    • Evidence based Interventions in descending order:
    • 􀂊 psychological therapy (A)
    • 􀂊 pharmacological therapy (antidepressant medication) (A)
    • 􀂊 self-help (A)
    • 4. The treatment option of choice should be available promptly. (D)
    • 5. positive advantages of services based in primary care
  • 22.
    • Psychological interventions
    • 6. CBT should be used. (A)
    • 7. delivered only by suitably trained and supervised people who adhere closely to empirically grounded treatment protocols.
    • 8. optimal range of duration (16-20 hours)
  • 23.
    • 9. weekly sessions of 1-2 hours completed within 4 months
    • 10. briefer CBT supplement with appropriate focussed information and tasks. (A)
    • 11. Where briefer CBT is used, it should be around 8-10 hours and be designed to integrate with structured self-help materials
  • 24.
    • Pharmacological interventions
    • 12. The following must be taken into account:
    • 􀂊 the age of the patient (D)
    • 􀂊 previous treatment response (D)
    • 􀂊 risks
    • 􀂊 the likelihood of accidental overdose
    • 􀂊 the likelihood of deliberate self harm
    • tolerability (D)
    • 􀂊 the preference of the person being treated (D)
    • 􀂊 cost, where equal effectiveness is demonstrated
  • 25.
    • 15. An SSRI should be offered. (B)
    • 16. If no improvement after 12-week course, another SSRI
    • 17. Consider the following
    • 􀂊 start at a low dose and increasing the dose slowly
    • 􀂊 In some instances, high doses might be needed. (B)
    • 􀂊 Long-term treatment may be necessary for some
    • 􀂊 If the patient is showing improvement continue for at least 6 months after the optimal dose is reached
  • 26.
    • Self-help interventions
    • 25. Bibliotherapy based on CBT principles (A)
    • 26. Information about support groups, if available,
    • 27. Large group CBT should be considered. (C)
    • 28. The benefits of exercise be discussed (B)
    • 29. CBT via a computer interface (CCBT)
  • 27.
    • Recommendations
    • 1. CBT should be used. (A)
    • 2. CBT has been found to maintain its effectiveness when examined after long term follow up (8-14 years). (Ib)
    • 3. Most patients at longer term follow up maintained treatment gains.
    • 4. In large group settings, CBT more effective than attention placebo, both in the short and long term. (Ib)
    • 5. CBT is effective for GAD in older people. (Ib)
  • 28.
    • 6. more effective than psycho dynamic therapy and non-specific treatments (Ia)
    • 7. more contact with therapist (16-20 sessions) did not result in better outcomes than less contact (8-10 sessions). (Ib)
    • 8. Anxiety management training, relaxation and breathing therapy are more effective than no intervention. (Ia)
  • 29.
    • Research evidence (summary)
    • Cognitive and behavioural techniques combined had greater effect sizes than the individual interventions. (Ia)
    • 2. In the short term, cognitive and behavioural techniques were as effective as pharmacological therapies, but evidence is lacking for long term effectiveness. (Ia)
    • 3. no difference in treatment outcomes for men and women.
  • 30.  
  • 31. CBT in Pak: Intial findings
    • Findings from Qualitative study
    • Interview with 7 psychologists
    • Therapists
    • REBT background
    • Diagnoses/problems
      • Anxiety disorders and depression (60-70%)
      • Family conflicts, bereavement, other
  • 32.
    • Logistics
    • Number per day (3-8)
    • Referrals (psychiatrists )
    • Follow up (<30%)
    • Number of planned sessions upto 12
    • Gap between sessions 1 to 4 weeks
    • Always along with medical treatment
  • 33.
    • Presenting complaints
      • Mainly somatic somatic
    • Poor follow up
      • Distance and money
      • Female gender
      • Low social status and lack of education
      • Pills oriented and not psychological minded
      • What about role of faith healers?
  • 34.
      • Psychiatrists don’t refer properly
      • Psychiatrists don’t know much about therapy
      • Patients don’t come back when they are symptoms free
    • Process of therapy
      • Assessment, family involvement
      • List of strengths and difficulties
      • List of presenting complaints
      • Psychometric tests
  • 35.
    • Therapy ingredients
      • Supportive therapy
      • Psycho education
      • Psychotherapy
      • Family work
    • Common techniques
    • cognitive errors teaching
    • cognitive restructuring
  • 36.
      • Problem solving
      • Social skills
      • Assertiveness training
      • Monitoring mood
      • Communication skills
      • Work on irrational beliefs
      • Behavioural methods
  • 37.
    • Hurdles in therapy
    • homework
    • Problems will be solved in 1 st session
    • personal satisfaction
    • therapists factors
    • explaining cognitive errors (translation)
    • negative thoughts (people don’t like it)
    • family involved too much
    • Involvement of non medical healers?
  • 38.
    • Overcoming hurdles
      • Take into consideration hurdles
      • Coping statements (& prompt cards)
      • Biblio therapy
      • Cultural context
      • patients think its gupshup 
      • One single message from each session
      • Use of imagery
  • 39.
      • Repeat, shorter gaps
      • Rapport
      • Use of tapes, written material
    • Style of therapy
    • instructional not collaborative
    • authoritative not authoritarian
    • giving direct advice or Socratic dialogue
  • 40. Causes of anxiety disorders
    • Long term predisposing causes
    • heredity
    • childhood circumstances
      • overprotective parents
      • over critical parents
      • emotional insecurity and dependence
      • controlling parents
      • parents who make child feel guilty or ashamed
  • 41.
    • parental neglect (emotional)
    • parental abuse
    • cumulative stress over time
    • childhood abuse (physical, sexual or emotional)
    • other illnesses insecurities
    • other problems which cause low self esteem
  • 42.
    • Biological causes
      • physiological disease, chronic illness
      • drug or alcohol abuse
      • psychological causes
      • stress ongoing or acute
      • trauma
      • personality
      • another psychiatric condition
  • 43.
    • underlying beliefs
    • ongoing stresses
    • lack of assertiveness
    • lack of self nurturing skills
    • muscle tension or other bodily symptoms
    • stimulants and dietry factors
    • high stress lifestyle
  • 44.
      • lack of meaning or purpose in life
      • working without breaks
      • withheld feelings
    • Drugs and Medical conditions that cause anxiety or panic
      • Hyperventilation
      • Hypoglycaemia
      • Hyperthyroidism
      • Mitral valave prolapse
  • 45.
    • Precipitating (triggering) causes
      • any significant stress or life event (- or +)
      • personal loss
      • life changes
      • drugs (pharmacological or recreational)
      • Trauma
    • maintaining causes
      • avoidance of some situations (if situational)
      • unhelpful thoughts (cognitive errors)
  • 46.
      • Premenstrual syndrome
      • Inner ear disturbances
      • Chronic disease
      • Cocaine, amphetamine, caffeine, other stimulants,
      • Withdrwawl from alcohol, sedative hypnotics or tranquilisers
      • Cushing syndrome
      • Parathyroidism
      • Complex partial seizures
  • 47.
      • Post concussion syndrome
      • Deficiencies of calcium, magnesium, postassium, niacin, vitamin B12
      • Emphysema
      • Pulmonary embolism
      • Cardiac arrythmias
      • Congestive heart failure
      • Essential hypertension
      • Toxins: mercury, carbon dioxide, food addititves, pesticides
  • 48.  
  • 49.
    • Sharing your understanding with the patient
  • 50. Assessment
    • Demographic data
    • Presenting complaints, concerns
    • Description of the current episode
    • Comorbid disorders
    • Medical history
    • Past history
  • 51.
    • Personal history
    • Patients perception of problem
    • Family history
    • Social history
    • Personality assessment
    • Coping skills
  • 52. Principles of assessment
    • Therapeutic relationship (warmth, empathy, genuineness, trust)
    • Explore patients ideas about medical system
    • cause of problems and treatment
    • Prepare the patient for cognitive therapy
    • Collaboration Vs instructions
    • Balance (not being too brief or too detailed)
    • Body language
  • 53.
    • Reflection, repetition and summarizing
    • Questioning not answering
    • Ask for examples to get a clear picture
    • Supervision and training
    • Use of scales
    • Be natural
    • Enjoy it
  • 54. Use of scales
    • Screening or diagnostic
    • Measurement of change
    • hospital anxiety and depression
    • beck anxiety scale
    • Hamilton anxiety scale
    • Pakistan anxiety and depression scale
    • Bradford somatic inventory
  • 55. Comprehensive management
    • Physiological level
      • Psycho education, support
      • reduce arousal, Breathing, muscle relaxation
    • Emotional level
      • Suppressed feelings
      • Learning to express your feelings
      • Communicate properly (assertiveness, communication skills)
  • 56.
    • Behavioural level
      • activity scheduling
      • aerobic exercises
      • eliminate avoidance behaviours
      • address problem behaviours
      • problem solving
      • coping techniques
  • 57.
    • Mental and Psychological level
      • self talk (worrying thoughts, cognitive errors)
      • dealing with cognitive errors
      • dealing with underlying beliefs
      • anger, shame and guilt
  • 58.
    • Interpersonal level
      • Conflict management
      • Communication skills
      • Assertiveness
      • How to deal with an aggressive or controlling person
      • Time management
  • 59.
    • whole self level
      • Low self esteem
      • Confidence building
    • Spiritual and religious level
    • Lifestyle and diet etc.
    • Use of Medication
  • 60. Relaxations exercises
    • Rationale for relaxation exercise
    • Role of autonomic nervous system overactivity
    • Use of hyperventilation to induce anxiety or panic
    • Variety of techniques
    • Which method or style is best?
    • Progressive muscle relaxation
    • breathing exercise
  • 61.
    • Imagery
    • Mindfulness (body, environment & thoughts)
    • Meditation
    • Focusing on a point
    • Repeated religious words (wird)
    • Counting breaths (allah ho)
  • 62.
    • Breathing & muscle relaxation
  • 63. Principles of time management
    • Prioritization
    • Delegation
    • Allowing extra time
    • Beware of perfectionsistic traits
    • Think about ambition, greed and overinvolvement with work
    • Saying no
    • Making list of things
    • Using a diary
  • 64. Distraction techniques
    • Talk to someone
    • Focus on subjects in your surroundings
    • Do simple, repetitive tasks (count, wird etc.)
    • Coping strategies
    • Engage in physical activity
    • Do something pleasureable
  • 65. Self talk
    • worrier
        • anticipating the worst
        • overestimating the odds of bad things happening
        • creating grandiose images or potential of failure or
        • catastrophe
    • the critic
        • always judges you and your actions
        • always draws attention to your shortcomings
        • compares with others and think of them as better
        • ignores your positive qualitites
  • 66.
    • Victim
      • always feels hopeless or helpless
      • always complains about things
      • something wrong with you (deprived, defective or
      • unworthy)
      • need for approval and agreement from others
      • dependence on others (emotional, physical,
      • psychological)
  • 67.
    • Perfectionist
      • your efforts are not good enough
      • you should work even harder
      • you should always have things under your control
      • people are either good or bad nothing in between
      • should always make people happy
      • should always succeed
      • should always be humble
  • 68. How to deal with these self talks
    • What is the evidence for this
    • Is this always true
    • Has this been true in the past
    • What are the odds of this being true
    • What is the worst that could happen
    • Am I looking at the whole picture
  • 69.
    • Downward arrow technique
    • Socratic dialogue
    • Identify common statements
    • Prepare counterstatements
      • avoid negatives
      • keep in present sense
      • keep in first person
      • there must be some belief in statement
      • some evidence of the statement
  • 70.
    • Downward arrow technique
    • Socratic dialogue
  • 71.
    • What is your coping style
  • 72. Coping (strategies) with stress
    • physical strategies
    • relaxation
    • diet
    • exercise
    • taking breaks
    • time managemengent
    • sleep hygiens
    • environment
    • material security
    • Emotional strategies
    • social support and relatedness
    • self nurturing
    • assertiveness
    • good communication
    • assertiveness
    • recreational activities
    • emotional releasse
    • sense of humour
  • 73.
    • Cognitive strategies
    • flexible, constructive and alternative thinking
    • distraction
    • task oriented (vs reactive)
    • Positive Self talk
    • spiritual
    • acceptance and forgiveness
    • tolerance & patience
    • trust in others
    • faith in good outcome of future
    • purpose of life and work
    • religious/spiritual life
  • 74. Communication & conflicts
    • Avoid batteling with the other person
    • Agree to disagree
    • I statement rather than vague statements
    • Avoid judgements
    • don’t jump to conclusions
    • Refer to other persons particular behaviour
    • Avoid generalistation
  • 75. Assertiveness tips
    • Styles
      • Passive
      • Aggressive
      • Manipulative
      • Assertive
    • Pakistani cultural context
    • religious aspects
  • 76.
    • Principles
      • Express your feelings
      • Ask for what you want (specific)
      • Say no to something you don’t want
  • 77. Tips on assertiveness
    • Non verbal assertive behaviour
      • Looking directly at another person
      • Body language (e,g; crossing arms etc.)
      • Don’t move away (don’t leave the room)
      • Stay calm
    • Know their human rights and assert them
      • Read on basic human rights
  • 78.
    • Be aware of what you want (decision making)
      • Be clear about what you want
      • Know your feelings
      • What you want and what you don’t want
    • Practice and plan
      • Speicify the situation and your reponse
      • Specific, clear, concise, not long vague story
      • Write or prepare a statement
  • 79.
    • developing a response
      • evaluate your rights
      • decide on a time and place
      • address the main person(s)
      • state the problems in terms of specific relation with you
      • express your feelings (I statments)
      • suggest an alternative(s)
      • talk about specific (realistic) consequences
      • start with less threatening or less authoritarian person
  • 80.
    • Practising assertion: role play
  • 81. Learn to say no
    • Acknowledge the other persons request by repeating it
    • Explain your reason for declinging
    • (in pak always keep a list of excuses)
    • say no
    • suggest an alternative
    • take your time (give me some time to think about it)
    • don’t apologize too much
    • be speficic
    • assertive body language
    • dealing with guilt
  • 82. role playing, real life
  • 83. Nutrition and parhez
    • Foods that aggravate anxiety
    • Caffeine, Nicotine, alcohol
    • Stimulant drugs
    • High salt diet
    • chocolate
    • Preservatives
    • Red meat and animlas fed on hormones
    • Eating habits
      • Eating quickly (mindful eating)
      • No chewing (15-20 mouthfuls)
      • Eating too muc Drinking too much fluid during meal
    • Sugar and hypoglycaemia
    • Food allergy
  • 84. Good diet for reducing anxiety
    • Eat more vegetables and fruits
    • More raw vegetables
    • Careful with what you eat
    • Stop eating refined and processed foods
    • Stop food that causes allergy, stomach or other discomfort
    • Less red meat
    • Increase dietry fibre
    • Drink plenty of water
    • less fat and carbohydrates
  • 85.
    • Supplements for anxiety
      • B and C vitamins
      • Calcium and magnesium supplements
      • Relaxing herb
      • Kava
      • Valerian
      • St johns wort
      • Passionflower
      • Gotu kola
      • Ginkgo biloba
  • 86. Problems solving approach
    • Defining the problem
      • (1) helpful in making a positive change
      • (2) specific
      • (3) is the outcome likely to be measureable
    • Steps in problems solving
      • thinking about possible solutions
  • 87.
      • looking at the cost and benefit of each solution
      • choose the most appropriate (realistic) solution
      • now break down this solution into as many steps as possible
      • execute your plan
      • review your outcome
  • 88.
    • Practice problem solving
  • 89. Identifying and expressing feelings
    • Identifying feelings
      • Exercise on recognizing moods
      • Discriminate feelings
      • Mood diary
      • Meditation and mindfulness
    • Symptoms of suppressed feelings
      • anxiety
      • depression
      • psychosomatic symptoms
      • muscle tension
  • 90.
    • What are the common types of emotions
  • 91.
    • Common types of emotions
    • Depressed Anxious Angry Ashamed Excited
    • Frightened Irritated Panicky Frustrated happy
  • 92.
    • How to be aware of feelings
      • Relaxation breathing
      • Mindfulness
      • Ask yourself
      • Tune into the place of emotions (heart, abdomen, mind)
      • Wait and listen
  • 93.
    • Ask the patient how he/she might feel when in these situations.
          • you have failed the exam
          • you have lost your job
          • you are lying in your bed and you hear a big explosions
          • you have been caught while stealing from a shop
          • your friend has told you off for no reasons
          • you have been offered a job
  • 94. Dealing with cognitive errors
  • 95. Teaching on thoughts
    • What are thoughts (types)
    • How to distinguish them from emotions
    • Negative automatic thoughts
      • They are automatic -
      • They are unhelpful -
      • They are believable -
      • They are persistent
  • 96.
    • Types of thoughts
      • Jumping to conclusions .
      • Selective abstraction
      • Overgeneralisation
      • Magnification or minimisation
      • Personalisation
      • All or nothing thinking
  • 97. How to discover thoughts
    • Exploring cognitive errors
  • 98. Thought diaries
  • 99. Thoughts (Words, images, or memories) Mood Feeling, sensations Situation What? Who? When? Where?,
  • 100. Evidence that does Not Support the Thought Evidence That Supports The thoughts Negative Automatic thoughts Mood Feeling, sensations Situation What? Who? When? Where?
  • 101. Alternat ive Thought (s) Evidence that does not support the Thought Evidence that Supports the thoughts Negative Automatic thoughts Mood Feeling, sensations Situation What? Who? When? Where?
  • 102.
    • questions to help in thinking of evidence that does not support the thoughts
      • what would my brother/sister/friend would think if in a similar
      • situations
      • what would have I thought if this had happened in the past, or
      • when I was not so depressed/anxious
      • what would I think if this happens few moths from now on
      • when I am a little better
      • if my friend was thinking like this what would have I said
      • try to think of similar situations in the past, and what did you
      • think then
  • 103. Dysfunctional beliefs and assumptions
    • Use of youngs schema questionnaire
    • Downward arrow technique
    • Education and awareness of beliefs
    • Specific techniques to change beliefs
  • 104.  
  • 105.  
  • 106.  
  • 107.  
  • 108.  
  • 109.  
  • 110.  
  • 111.