Transcript 5 - Anxiety Disoders

Anxiety Disorders
Biological Findings
• GAD and Panic D/o
– GABA Theory
•
•
•
•
problem binding to the BZD receptors
Altered receptor sensitivity
Abnormal NE and 5-HT neurotransmission
Studies have shown CO2 inhalation precipitates panic
attacks
• OCD
– if obsessions are r/t a defect in neural inhibition of
dominant frontal systems
– 5-HT neurotransmission is dysregulated
Biological Findings (cont)
• PTSD
– Extreme stress is assoc with damaging effects
to the brain
– Abuse causes reduction in the hippocampus
(Bremner, et al 1997)
Psychological Factors
• Psychodynamic
– Anxiety results from breakthrough of
repressed ideas and emotions
– Ego defense mechanisms are used to help
manage anxiety
• Interpersonal
– Anxiety is linked to the emotional distress
caused when early needs go unmet
Psychological Factors (cont)
• Learning Theories
– Anxiety is a learned response that can be
unlearned
– Learn to be anxious through modeling
• Cognitive Theories
– Anxiety is caused by distortions in thinking
and perceiving
Anxiety Disorders
1. Panic Disorder
2. Generalized Anxiety Disorder (GAD)
3. Phobias
Panic Anxiety Disorder
A. Recurrent unexpected panic attacks. A panic attack is
an abrupt surge of intense fear or intense discomfort
that reaches a peak within minutes, and during which
time four (or more) of the following symptoms occur:
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.
Panic Anxiety Disorder
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.
• Note: Culture-specific symptoms (e.g., tinnitus, neck
soreness, headache, uncontrollable screaming or crying)
may be seen. Such symptoms should not count as one
of the four required symptoms.
Panic Anxiety Disorder
B. At least one of the attacks has been followed by 1
month (or more) of one or both of the following:
1. Persistent concern or worry about additional panic
attacks or their consequences.
2. A significant maladaptive change in behavior related
to the attacks.
Panic Anxiety Disorder
C. The disturbance is not attributable to the physiological
effects of a substance or another medical condition.
D. The disturbance is not better explained by another
mental disorder.
Panic Anxiety Disorder with
Agoraphobia
 If the condition is accompanied with excessive fear
from the attack to occur that is the person develops
phobic avoidance to situations in which a sense being
alone in public places from which escape might be
difficult or in which help is not available.
Panic Anxiety Disorder
• Prevalence
• In the general population, the 12-month prevalence
estimate for panic disorder across the United States
and several European countries is about 2%-3% in
adults and adolescents.
• Females are more frequently affected than males, at a
rate of approximately 2:1
• Suicide Risk
• Panic attacks and a diagnosis of panic disorder in the
past 12 months are related to a higher rate of suicide
attempts and suicidal ideation
• Functional Consequences of Panic Disorder
• Panic disorder is associated with high levels of social,
occupational, and physical disability.
• “I always thought I was just a worrier. I’d
feel keyed up and unable to relax. At
times it would come and go, and at
times it would be constant. It could go
on for days. I’d worry about what I was
going to fix for a dinner party, or what
would be a great present for somebody.
I just couldn’t let something go.”
• When my problems were at their worst,
I’d miss work and feel just terrible about
it. Then I worried that I’d lose my job.
My life was miserable until I got
treatment.
Generalized Anxiety Disorder
A. Excessive anxiety and worry (apprehensive
expectation), occurring more days than not for at least 6
months, about a number of events or activities (such as
work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or
more) of the following six symptoms (with at least some
symptoms having been present for more days than not
for the past 6 months);
Generalized Anxiety Disorder
Note: Only one item is required in children.
1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep,
or restless, unsatisfying sleep).
D. The anxiety, worry, or physical symptoms cause
clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Generalized Anxiety Disorder
E. The disturbance is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition (e.g.,
hyperthyroidism).
F. The disturbance is not better explained by another
mental disorder
Generalized Anxiety Disorder
• Prevalence
• The 12-month prevalence for the disorder in other
countries ranges from 0.4% to 3.6%.
• Females are twice as likely as males to experience
generalized anxiety disorder.
• Functional Consequences of Generalized Anxiety
Disorder
• Excessive worrying impairs the individual's capacity to
do things quickly and efficiently, whether at home or
at work. The worrying takes time and energy; the
associated symptoms of muscle tension and feeling
keyed up or on edge, tiredness, difficulty
concentrating, and disturbed sleep contribute to the
impairment.
Phobias
Phobias
• Irrational fear of an object, situation that is recognized
by the person as being unreasonable
• Types:
1. Agoraphobia
2. Specific Phobia
3. Social Phobia
Agoraphobia
A. Marked fear or anxiety about two (or more) of the
following five situations:
1. Using public transportation
2. Being in open spaces
3. Being in enclosed places
4. Standing in line or being in a crowd.
5. Being outside of the home alone.
B. The individual fears or avoids these situations
because of thoughts that escape might be difficult or
help might not be available in the event of developing
panic-like symptoms or other incapacitating or
embarrassing symptoms
Agoraphobia
C. The agoraphobic situations almost always provoke
fear or anxiety.
D. The agoraphobic situations are actively avoided,
require the presence of a companion, or are endured
with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual
danger posed by the agoraphobic situations and to the
sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically
lasting for 6 months or more.
Agoraphobia
G. The fear, anxiety, or avoidance causes clinically
significant distress or impairment in social, occupational,
or other important areas of functioning.
H. If another medical condition is present, the fear,
anxiety, or avoidance is clearly excessive.
I. The fear, anxiety, or avoidance is not better explained
by the symptoms of another mental disorder.
Note: Agoraphobia is diagnosed irrespective of the
presence of panic disorder.
Agoraphobia
• Functional Consequences of Agoraphobia
• Agoraphobia is associated with considerable
impairment and disability in terms of role functioning,
work productivity, and disability days.
Specific Phobia
D. The fear or anxiety is out of proportion to the actual
danger posed by the specific object or situation and to
the sociocultural context.
E. The fear, anxiety, or avoidance is persistent, typically
lasting for 6 months or more.
F. The fear, anxiety, or avoidance causes clinically
significant distress or impairment in social, occupational,
or other important areas of functioning.
Specific Phobia
A. Marked fear or anxiety about a specific object or
situation (e.g., flying, heights, animals, receiving an
injection, seeing blood).
Note: In children, the fear or anxiety may be expressed by
crying, tantrums, freezing, or clinging.
B. The phobic object or situation almost always provokes
immediate fear or anxiety.
C. The phobic object or situation is actively avoided or
endured with intense fear or anxiety.
About Specific Phobia
• The average individual with specific phobia fears
three objects or situations, and approximately 75% of
individuals with specific phobia fear more than one
situation or object
• Prevalence:
• In the United States, the 12-month community
prevalence estimate for specific phobia is
approximately 7%-9%. but rates are generally lower
in Asian, African, and Latin America
• Females are more frequently affected than males, at
a rate of approximately 2:1, although rates vary
across different phobic stimuli.
Specific Phobia
• Specific phobia sometimes develops following:
1. a traumatic event
2. observation of others going through a traumatic
event
3. an unexpected panic attack in the to be feared
situation
4. or informational transmission
• However, many individuals with specific phobia
are unable to recall the specific reason for the
onset of their phobias.
Phobia Top 10
1.Arachnophobia
2.Social Phobia
3.Aerophobia
4. Agoraphobia
5.Claustrophobia
6.Acrophobia
7.Emetophobia
8.Carcinophobia
9.Brontophobia
10.Necrophobia
Social Anxiety Disorder (Social Phobia)
A. Marked fear or anxiety about one or more social
situations in which the individual is exposed to
possible scrutiny by others.
• Examples include social interactions (e.g., having
a conversation, meeting unfamiliar people), being
observed (e.g., eating or drinking), and
performing in front of others (e.g., giving a
speech).
• Note: In children, the anxiety must occur in peer
settings and not just during interactions with
adults.
Social Phobia
B. The individual fears that he or she will act in a way or
show anxiety symptoms that will be negatively evaluated
(i.e., will be humiliating or embarrassing: will lead to
rejection or offend others).
C. The social situations almost always provoke fear or
anxiety.
Note: In children, the fear or anxiety may be expressed
by crying, tantrums, freezing, clinging, shrinking, or
failing to speak in social situations.
D. The social situations are avoided or endured with
intense fear or anxiety.
Social Phobia
E. The fear or anxiety is out of proportion to the actual
threat posed by the social situation and to the
sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically
lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically
significant distress or impairment in social, occupational,
or other important areas of functioning.
H. The fear, anxiety, or avoidance is not attributable to
the physiological effects of a substance or another
medical condition.
Social Phobia
I. The fear, anxiety, or avoidance is not better
explained by the symptoms of another mental disorder
J. If another medical condition the condition is worsened
Social Phobia
• Prevalence
• The 12-month prevalence estimate of social
anxiety disorder for the United States is
approximately 7%.
• Lower 12-month prevalence estimates are seen
in much of the world around 0.5%-2.0.
• Functional Consequences of Social Anxiety
Disorder
• Social anxiety disorder is associated with
elevated rates of school dropout and with
decreased well-being, employment, workplace
productivity, socioeconomic status, and quality of
life.
Social Phobia
• Comorbidity
• Social anxiety disorder is often comorbid with
other anxiety disorders, major depressive
disorder, and substance use disorders.
• “I couldn’t do anything without rituals.
They invaded every aspect of my life.
Counting really bogged me down. I
would wash my hair three times as
opposed to once because three was a
good luck number and one wasn’t. It
took me longer to read because I’d
count the lines in a paragraph. When I
set my alarm at night, I had to set it to a
number that wouldn’t add up to a ’bad’
number.”
• “I knew the rituals didn’t make sense,
and I was deeply ashamed of them, but
I couldn’t seem to overcome them until I
had therapy.”
• “Getting dressed in the morning was
tough, because I had a routine, and if I
didn’t follow the routine, I’d get anxious
and would have to get dressed again. I
always worried that if I didn’t do
something, my parents were going to
die. I’d have these terrible thoughts of
harming my parents. That was
completely irrational, but the thoughts
triggered more anxiety and more
senseless behavior. Because of the
time I spent on rituals, I was unable to
do a lot of things that were important to
me.”
Obsessive-Compulsive and
Related Disorders.
Obsessive-Compulsive Disorder
A. Presence of obsessions, compulsions, or both:
• Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or images
that are experienced, at some time during the
disturbance, as intrusive and unwanted, and that in most
individuals cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such
thoughts, urges, or images, or to neutralize them with
some other thought or action.
Obsessive-Compulsive Disorder
• Compulsions are defined by (1) and (2):
• 1. Repetitive behaviors (e.g., hand washing,
ordering, checking) or mental acts (e.g., praying,
counting, repeating words silently) that the
individual feels driven to perform in response to an
obsession or according to rules that must be applied
rigidly.
• 2. The behaviors or mental acts are aimed at
preventing or reducing anxiety or distress, or
preventing some dreaded event or situation;
however, these behaviors or mental acts are not
connected in a realistic way with what they are
designed to neutralize or prevent, or are clearly
excessive.
Obsessive-Compulsive Disorder
Note: Young children may not be able to articulate the
aims of these behaviors or mental acts.
B. The obsessions or compulsions are time-consuming
(e.g., take more than 1 hour per day) or cause clinically
significant distress or impairment in social, occupational,
or other important areas of functioning.
C. The obsessive-compulsive symptoms are not
attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication) or another medical
condition.
D. The disturbance is not better explained by the
symptoms of another mental disorder
Obsessive-Compulsive Disorder
• Prevalence
• The 12-month prevalence of OCD in the United States is
1.2%, with a similar prevalence internationally (1.1%1.8%).
• Females are affected at a slightly higher rate than males
in adulthood, although males are more commonly
affected in childhood.
• Suicide Risk
• Suicidal thoughts occur at some point in as many as
about half of individuals with OCD. Suicide attempts are
also reported in up to one-quarter of individuals with
OCD; the presence of comorbid major depressive
disorder increases the risk.
• Checking
…………………………..63%
• Washing
………………….….……50%
• Contamination…………….…….45%
• Doubting……………………….…..42
%
• Body fears………................... 36%
• Counting……………………..…….36
%
Obsessive-Compulsive Disorder
• Functional Consequences of Generalized Anxiety
Disorder
• Excessive worrying impairs the individual's capacity to
do things quickly and efficiently, whether at home or at
work. The worrying takes time and energy; the
associated symptoms of muscle tension and feeling
keyed up or on edge, tiredness, difficulty concentrating,
and disturbed sleep contribute to the impairment.
Body Dysmorphic Disorder
Body Dysmorphic Disorder
• A. Preoccupation with one or more perceived defects or
flaws in physical appearance that are not observable or
appear slight to others.
• B. At some point during the course of the disorder, the
individual has performed repetitive behaviors (e.g.,
mirror checking, excessive grooming, skin picking,
reassurance seeking) or mental acts (e.g., comparing his
or her appearance with that of others) in response to the
appearance concerns.
• C. The preoccupation causes clinically significant
distress or impairment in social, occupational, or other
important areas of functioning.
Body Dysmorphic Disorder
• D. The appearance preoccupation is not better explained
by concerns with body fat or weight in an individual
whose symptoms meet diagnostic criteria for an eating
disorder.
• Prevalence
• The point prevalence among U.S. adults is 2.4% (2.5%
in females and 2.2% in males).
• Suicide Risk
• Individuals with body dysmorphic disorder have many
risk factors for completed suicide, such as high rates of
suicidal ideation and suicide attempts, demographic
characteristics associated with suicide, and high rates
• of comorbid major depressive disorder.
Body Dysmorphic Disorder
• Functional Consequences of Body Dysmorphic
Disorder
• Nearly all individuals with body dysmorphic disorder
experience impaired psychosocial functioning because
of their appearance concerns. Impairment can range
from moderate (e.g., avoidance of some social
situations) to extreme and incapacitating (e.g., being
completely housebound).
Trauma and Stressor-Related Disorders
Posttraumatic Stress Disorder
Note: The following criteria apply to adults,
adolescents, and children older than 6 years. For
children 6 years and younger, see corresponding
criteria below.
A. Exposure to actual or threatened death, serious injury,
or sexual violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to
others.
3. Learning that the traumatic event(s) occurred to a
close family member or close friend. In cases of actual or
threatened death of a family member or friend, the
event(s) must have been violent or accidental.
Posttraumatic Stress Disorder
4. Experiencing repeated or extreme exposure to
aversive details of the traumatic event(s) (e.g., first
responders collecting human remains: police officers
repeatedly exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure through
electronic media, television, movies, or pictures, unless
this exposure is work related.
B. Presence of one (or more) of the following intrusion
symptoms associated with the traumatic event(s),
beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing
memories of the traumatic event(s).
Posttraumatic Stress Disorder
2. Recurrent distressing dreams in which the content
and/or affect of the dream are related to the traumatic
event(s).
Note: In children, there may be frightening dreams
without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the
individual feels or acts as if the traumatic event(s) were
recurring. (Such reactions may occur on a continuum,
with the most extreme expression being a complete loss
of awareness of present surroundings.)
Note: In children, trauma-specific reenactment may
occur in play.
Posttraumatic Stress Disorder
4. Intense or prolonged psychological distress at
exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external
cues that symbolize or resemble an aspect of the
traumatic event(s).
Posttraumatic Stress Disorder
C. Persistent avoidance of stimuli associated with
the traumatic event(s), beginning after the traumatic
event(s) occurred, as evidenced by one or both of
the following:
1. Avoidance of or efforts to avoid distressing memories,
thoughts, or feelings about or closely associated with the
traumatic event(s).
2. Avoidance of or efforts to avoid external reminders
(people, places, conversations, activities, objects,
situations) that arouse distressing memories, thoughts,
or feelings about or closely associated with the traumatic
event(s).
Posttraumatic Stress Disorder
D. Negative alterations in cognitions and mood
associated with the traumatic event(s), beginning or
worsening after the traumatic event(s) occurred, as
evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the
traumatic event(s) (typically due to dissociative
amnesia and not to other factors such as head injury,
alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or
expectations about oneself, others, or the world (e.g., “I
am bad,” “No one can be trusted,” ‘The world is
completely dangerous,” “My whole nervous system is
permanently ruined”).
Posttraumatic Stress Disorder
3. Persistent, distorted cognitions about the cause or
consequences of the traumatic event(s) that lead the
individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror,
anger, guilt, or shame).
5. Markedly diminished interest or participation in
significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions
(e.g., inability to experience happiness, satisfaction, or
loving feelings).
Posttraumatic Stress Disorder
E. Marked alterations in arousal and reactivity
associated with the traumatic event(s), beginning
or worsening after the traumatic event(s) occurred,
as evidenced by two (or more) of the following:
1. Irritable behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical
aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying
asleep or restless sleep).
Posttraumatic Stress Disorder
F. Duration of the disturbance (Criteria B, C, D, and E) is
more than 1 month.
G. The disturbance causes clinically significant distress
or impairment in social, occupational,
or other important areas of functioning.
H. The disturbance is not attributable to the physiological
effects of a substance (e.g., medication, alcohol) or
another medical condition.
Posttraumatic Stress Disorder
3. Persistent, distorted cognitions about the cause or
consequences of the traumatic event(s) that lead the
individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror,
anger, guilt, or shame).
5. Markedly diminished interest or participation in
significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions
(e.g., inability to experience happiness, satisfaction, or
loving feelings).
Treatment Modalities
Emergency Care
Interventions for Panic Attack
• Stay with the patient.
• Reassure him/her that you will not leave.
• Give clear directions.
• Assist patient to an environment with minimal
stimulation.
• Walk with the patient.
• Administer PRN anxiolytic medications.
Psychological Interventions

Behavioral therapy: • Cognitive therapy:
Thought
stopping
Response prevention
Cognitive restructuring
Relaxation techniques
Positive self-talk
Systematic desensitization Distraction
Imagery thinking
Floating
Cognitive-Behavioral Therapy
• The cognitive part helps people change the
thinking patterns that support their fears, and
the behavioral part helps people change the
way they react to anxiety-provoking situations.
• For example,
• CBT can help people with panic disorder learn
that their panic attacks are not really heart
attacks
• help people with social phobia learn how to
overcome the belief that others are always
watching and judging them.
• When people are ready to confront their fears,
they are shown how to use exposure
techniques to desensitize themselves to
situations that trigger their anxieties.
Behavioral models
1. Relaxation techniques
- Regular breathing
- Deep breathing
- Biofeedback
- Progressive relaxation techniques
- Normal breathing
Systematic Desensitization
- First collect data ( several sessions)
- Practice relaxation techniques
- Development of anxiety hierarchy
- Systematic desensitization ( ..
1. Imagine the least anxiety-arousing scene
2. Then moving up with the hierarchy until
reaching the anxiety state
3. Homework and follow ups.
Exposure Therapy
- Systematic desensitization (imagined)
- In vivo desensitization ( actual)
- Flooding: imagined and in vivo (actual)
- Eye Movement Desensitization and
reprocessing (EMDR): includes imagined
flooding, cognitive restructuring, rapidrhythmic eye movement, and bilateral
stimulation
Interventional models
• Supportive therapy
• Psychoeducation
• Individual therapy
• Family therapy
• Marital therapy
• Milieu therapy
Nursing Management:
Social Domain
• Consider sociocultural factors and patient’s
ability to relate to others.
• In the hospital, unit routines are carefully and
clearly explained to decrease patient’s fear of
unknown.
• Recognize significance of personal rituals.
• Assist patient in arranging schedule for a day.
Psychopharmacologic
Treatment
1. Selective serotonin reuptake inhibitors
(SSRIs)
2. Tricylcic antidepressants
3. Benzodiazepines
4. Monoamine Oxidase Inhibitors
General Principles of CBT
• Thorough Behavioural
Assessment before
Treatment begins
• All aspects of Therapy are
made explicit to Patient
• Collaborative effort between
Patient & Therapist
• Main goal of CBT is to help
Patients bring about desired
• CBT is time-limited with
changes in their lives
explicit goals
• Treatment focuses on new
learning and generalization • Emphasis on the Here &
Now
outside the Therapy room
 Patient is helped to
• Problem-solving is an
recognize patterns of
important element in CBT
distorted thinking &
dysfunctional behaviour
Language & CBT
• Language is not neutral –
Statements of Fact V. Statements of Value
• Certain kinds of words = emotional &
judgemental
(eg) Mistake v. Error; Blame V
Responsibility
• Absolute types of words such as “Always /
Never” lead to certain types of feelings and
leave us little room to manoeuvre,
emotionally speaking

Catch all type words (eg) “Upset /Awful
/Terrible”

Taking Responsibility – encourage use of
“I” rather than accept “You/One”

Alexithymia = “Emotional Illiteracy” –
person does not have the words to
express feelings / emotions – Feelings list

Socratic Questioning

Sensations V Feelings V Emotions
CBT Treatment of
Anxiety, Panic & Phobias
• Exposure to the feared stimulus – Encourage
Disconfirming experiences & Self-Mastery
• Discourage Safety seeking behaviours in real life
• Behavioural Experiments
• Graduated Desensitization/Hierarchy of Feared
Situations/Objects/Stimuli
• Cognitive Re-Structuring/Interweave
• Challenge Pt’s Thoughts/Beliefs/ Assumptions
• “Court Room Drama” (Dunne)
• Review each session with Pt
• Begin next session with Review of past week
 Relapse Prevention
CBT Treatment of Life Stage, Existential,
Bereavement & Health Anxieties
• Resource Building
• Supportive Therapy
• Normalize the
Anxieties/PAs associated
with each major Life
Transition (eg) Becoming a
fully functioning
autonomous adult; Doubts
& Identity Issues @ Midlife;
Retirement & Old age
• Build up a store of
anecdotes & stories
• Judicious self-disclosure
can be helpful
• Suggest Reading on key
themes (eg) Victor
Frankl’s “Man’s search for
Meaning”
• Validate & Legitimize the
Patient’s experiences
 Present Focus in crisis
Treatment of PTSD
• Aim is not Cure but Affect Regulation
• Remember Relaxation Training and Non-Directive
Therapy are contra-indicated for treating PTSD (NICE,
2005)
• Effective Treatment of PTSD is not about Re-living the
experience but helping the Pt let go of the strong affect
and experience safety in the present
• Mindfulness by both Therapist and Pt are important in
the process
• “That was then, this is now” approach
• Bottom up approach rather than traditional Top down
 Resource Building before any treatment begins
Treatment of PTSD: Fisher (2008)
• In traditional talking treatments, we tend to treat
thoughts, feelings, and body sensations as if
they were one and the same phenomenon:
For example, when we say, “I feel unsafe,”
• It could reflect a cognition: “I am never safe,”
“The world is not a safe place”
• It could mean an emotion: “I’m feeling
frightened”
 It could mean a bodily sensation: “My chest is
tight; my heart is racing; it’s hard to take a
breath”
Mindfulness in PTSD
• Mindfulness in therapy depends upon the therapist
becoming more mindful: slowing the pace of thinking
and talking, refraining from interpretation in favor of
observation, helping the patient begin to focus on the flow
of thoughts, feelings, and body sensations as these unfold
• Because mindful attention is present moment
attention, we use “retrospective mindfulness” to bring the
client into present time: “As you are talking about what
happened then, what do you notice happening inside you
now?”
 Curiosity is cultivated because of its role as an entrée
into mindfulness: “So, when you talk about your father,
your heart beats faster and you feel afraid. . . “
Treatment of PTSD
• Present Focus with emphasis on Safety in the Here
& Now
• Normalizing the body’s responses and somatic
experiences associated with the Trauma event
• Identify Negative Cognitions arising from the
Trauma - “What does that say about you as a
person?”
• Identify which level of NC this is
 Use Cognitive Interweave as and when appropriate
Treatment of PTSD
• Develop sense of Self-Efficacy for the Pt
• “Hindsight Bias”
• Binocular Effect
• Identify the Body’s “Old Stuff” reactions and
place it historically
• Encourage Pt to continue to breathe at all times
• Ground, de-brief and orient the Pt at end of
Therapy session
 Relapse Prevention
Conclusions
• Review Chart Expectations with group
• Summarize workshop overall themes
Evaluation sheets