Transcript Cognitive behavioural approach to Anxiety disorders



Explore the role of beliefs and behaviours in
maintaining anxiety difficulties
Consider cognitive behavioural interventions used
with anxiety.



Anxiety is a response to facing a challenging
or threatening situation. If a person perceives
that they are under threat their body rapidly
produces adrenaline that primes them to
respond to this threat.
What are the classic behavioural responses in
these types of situation?
(Westbrook et al 2001)

The classic behavioural responses in this type
of situation are fight (challenging the threat
directly), or flight (escaping or avoiding the
threat), although freeze (being physically or
mentally immobile) is another possible
reaction. (Westbrook et al 2001)
4 components:
Flight/fight
Heart
Races,
Physical
Recognition of danger
focus on danger
Thoughts
Feelings
Behaviour
Run away ,
freeze, Attack
The continuum principle
Emotional problems arise from
exaggerated versions of
Normal process

A sense of threat




Rumination and
Excessive focus on the threat
Persistent threatening
Thoughts and images of the
Threat.
Increased heart rate
palpitations
Changes to digestive system
nausea/ vomiting
Increased breathing
dizziness light headed
derealisation








Hypervigilance to cues
Focus on threat


Overestimation of
harm or danger occurring


(A potential focus for further anxious
predictions)
Environment: Perception of threat
:
Thoughts
Overestimate likelihood of the
harm or danger occurring
( Threatening imagery)
Underestimate ability to cope
ruminate
Fight or flight
Palpitations,
Vomiting
dizzyness
Mood
Physical
Behaviour
Avoidance , escape.
Seek reassurance
procrastinate , checking
( safety behaviours)
Irritable, anxious
Trigger
Perceived
threat
Problem
response :
thoughts,
behaviour and
or physiology
Fear remains in
tact: belief
unchanged
Fear is
unchallenged
Trigger
Acurately
Perceived threat
Cycle
disrupted
Alternative
response;
behavioural
experiment
Old belief
changes to a
realistic belief
Fear is
challenged
Behavioural principle
What we do is crucial in
maintaining or in changing
psychological states









Panic Disorder
Generalised Anxiety Disorder
Social anxiety
Obsessive Compulsive Disorder
Post Traumatic Stress Disorder
Health Anxiety/Hypochondriasis
Specific Phobias
Symptoms of anxiety are a major component of all
these disorders
The types of threat or danger with in a situation that
serves as a trigger for anxiety, varies between anxiety
disorders.



A persistent irrational fear of an object or
situation (5 categories: animals, blood
injury/injections, situational, uncommon or
atypical)
Physical arousal and high levels of anxiety
experienced when confronted with the feared
object or situation
Accompanied by avoidance
Environment
Thoughts
Heart racing Physiological
Hot
Shaky
Summer months: outdoor
activities , possibility of
wasps !!( hypervigilance)
(Feared consequences&
anxious predictions)
Wasps will
attack/harm me by
flying into my ears.
Emotion
ANXIETY If I see a wasp i will
pass out.
Behaviour
Cover ears and
Run away

Behavioural Experiments
 Involve testing predictions about physical, social or
psychological danger
 Focus is on belief change through experience
 Experiment must have a clear hypothesis from client,
followed by a task that tests out that belief in an
appropriate setting
 E.g. If I don’t wash all my food thoroughly, I’ll get food
poisoning. Eat some unwashed food, wait and see what
happens.




Target cognition: If I see a wasp I will Pass out
Alternative perspective: If I see a wasp ,i may experience anxiety symptoms
but i will not pass out
Experiment: look at pictures of wasps increasing in size, rate anxiety every
few minutes. Encouraged to drop safety behaviours such as looking a way.
Focus on bits of wasp.
Result: Did’nt pass out, anxiety reduced after 20 minutes. Belief in target
cognition gradually fell to 15%, while his belief in alternative perspective
increased to 80%.




Target cognition: Wasps will always attack me and fly into my ears and harm
me....
Alternative perspective: wasps can sting but do not attack people or
generally fly into ears to cause harm
Experiment: Ask others if this has ever happened to them, construct a survey
of questions eg, how often do you play, eat outside, have you ever been
stung by a wasp? If so where? Has a wasp ever flown into you ear? What
happened ?
Result:??
James (now 37) has always had a fear of spiders. He remembers hearing a story when he
was a child that a spider bit someone and this grew in to a lump. Some time later the lump
“hatched and hundreds of baby spiders crawled out”. When he was 6 he recalls that an
aunt attempted to help him overcome his fears with a toy rubber spider and kept on putting
it down his underpants. He was petrified and every time he pulled the toy out she would
hold him down and again place it in his pants. His mother finally intervened and stopped
the ‘intervention’.
When he sees a live spider he feels anxious and removes him self from the situation and
insists on someone removing the spider before he can enter the room. If he is at home
alone he calls friend to come and remove the spider, if no ones around he will shut the door
on that room and not go in there for days. He believes that if you kill a spider 10 will come
back. When he goes into the garden he scans and looks for webs and spiders. Before going
to bed he checks his bed to make sure no spiders are hiding between the sheets. When he
stays away from home on the first might he asks his girlfriend to check the room for him
while he stands behind her. They do not stay in old B&B but when away in the UK would only
stay in modern buildings, e.g., travel lodge, James hates feeling anxious about spiders and
fears that he will pass out if he gets to close to one.
He will not travel abroad because of his fear of spiders – and since hearing about the Funnel
web spider travelling to Australia would be the worst place on earth. This is particularly
problematic, as his GF of 11 years would like him to travel with her to visit her family and
hometown.
On seeing a spider on TV he feels anxious and either leaves the room or turns the channel.
He immediately turns pages of newspapers when he sees pictures of spiders. Before going
to see a new film at the cinema he scans reviews to see if they mention spiders and asks
people that have seen the movie if it have spiders in them.

Target cognition:? What thoughts could be put to the test

Alternative perspective: what’s the alternative

Experiment: What could james do??

Result: what are you hoping james might learn??

Come up with 3 experiments, could you use a survey at any point??



Social phobias often start in adolescence and are centred around a
fear of scrutiny by other people in comparatively small groups (as
opposed to crowds), usually leading to avoidance of social
situations. Unlike most other phobias, social phobias are equally
common in men and women.
They may be discrete (i.e. restricted to eating in public, to public
speaking, or to encounters with the opposite sex) or diffuse,
involving almost all social situations outside the family circle.Social
phobias are usually associated with low self-esteem and fear of
criticism.
They may present as a complaint of blushing, hand tremor, nausea,
or urgency of micturition, Avoidance is often marked, and in
extreme cases may result in almost complete social isolation.


(b)the anxiety must be restricted to or
predominate in particular social situations;
and
(c)the phobic situation is avoided whenever
possible.
:
Thoughts
I won’t know what to say, i will
freeze, everyone will think i am
so weird/stupid...
Ill blush /shake everyone will
know i am anxious and think I
am a weakling
Fight or flight
Tight chest
Heart racing
Mood
Physical
anxious
Behaviour
Try to avoid talking/ avoid social occasions
Rehearse what to say.
Try to hide anxiety/blushing etc

Key processes

Self focused attention (monitoring symptoms..)



Safety seeking eg... rehearsing what to say, hide blushing or
tremors..
Perceived social danger; Patients often believe that their behaviour
must fall into a narrow category to be acceptable to others.
Not coping ...
People will find me stupid or
boring and notice I am anxious
and blushing they will laugh at
me and make remarks
Thoughts
Fight or flight
Tight chest
Heart racing
Mood
Physical
anxious
Behaviour
Rehearse what to say. monitor for signs of blushing
put hair over face to hide.





Target cognition: If people notice that someone cheeks are red they will laugh, point
make remarks.
Alternative perspective: most people are engrossed in their own thoughts, activities etc
and may notice little else. If they do notice they are unlikely to react too obviously.
Prediction: people will notice and stop ,point ,stare, whisper
Experiment: Therapist made her cheeks red and went shopping with patient, patient to
observe others reactions.....
Result:????? Want to try it????



Characterised by:
Recurrent obsessive *( persistent and
intrusive thoughts, images or impulses)
And/or compulsions( compelling repetitive
behaviour or rituals or mental acts intended
to put right or neutralise the obsession)

Most common forms of OCD

Contamination fears....


Doubt and uncertainty in which people fear that something bad will happen if
they do not carefully check their behaviour or do something the right
number of times or in the right way......
Thoughts which the person sees as strongly inappropriate or immoral, often
associated with a fear that these thoughts imply that they might carry out
some objectionable action.....
Fear of causing harm
Driving /walking past
children
How far away is that child?
Did I bump into that child?
Now that I have had that
thought did i do it on purpose?
I must be certain that I did not
cause this child harm or else I
will not be able to get on with
anything
Thoughts
Fight or flight
Heart racing
Mood
Physical
anxious
Behaviour
Phone the child’s parents to check ( reassurance)
Start doubting the reassurance, phone again
Where possible avoid the school run

Inflated responsibility

Thought action fusion

Intolerance of uncertainty



Jane fears that she will contaminate herself and her
family with germs and has a catastrophic prediction
that a family member will be physically harmed as
a result of this contamination. She responds to
this fear by washing her hands constantly with
bleach and engages in elaborate cleaning rituals
Behavioural experiment, survey???
What do you need to take into consideration what
potential obstacles might exist?


A cognitive strategy which could be used in
this instance is the survey. Jane could make a
checklist to ask her friends what precautions
they take to avoid contamination with germs.
She could also ask how often their family
members get sick.
What would you hope that Jane would
discover through this?


Think about one of your own fears and
consider to what extent they are maintained
by the way you think about them and behave
in relation to them.
What behavioural experiments could you
carry out to test this out?

Could this approach to recognising and
working with anxiety benefit your nursing
practice ? Which aspects , where?? what would
make it difficult??



David M. Clark Anxiety disorders: why they
persist and how to treat them.Behaviour
Research and Therapy 37 (1999) S5-S27
Clark, D. (1989) Anxiety states in Hawton
et.al (eds) (1989) Cognitive Behaviour
Therapy for Psychiatric Problems,Oxford
medical, Oxford.
Wells, A. (1997) Cognitive Therapy of
Anxiety Disorders, John Wiley and Sons,
Chichester.