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Cbt for anxiety2


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Cbt for anxiety2

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