Transcript Treatment of Anxiety Disorders

Introduction to Cognitive
Behavioural Therapy in
the Treatment of Anxiety
Disorders
Dr Tim Dunne
Consultant/Registered Clinical Psychologist
Webster University, Geneva
5th & 6th November 2010
www.carlowpsychology.ie ©
th
5
November

Introduction to the workshop

Medical Conditions & Anxiety

Expectations & Ground Rules

The Triune Brain

Outline & Structure of Workshop

Importance of Breakfast
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Nature & Types of Anxiety
Healthy V. Clinical Anxiety

Case Study

Anxieties related to Existential
issues & Life Stage Transitions
th
6
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November
Therapeutic Universals of
Treatment
Factors Determining Outcome in
Therapy
Therapist/Patient Differences in
Expectations
Core Concepts of CBT
Treatment approach
Development of CBT
Language & CBT

Resource Building

Case Formulation in CBT &
Case Study

CBT & Treatment of Anxiety,
Panic Disorder & Phobias

CBT Treatment of Life Stage.
Existential & Health Anxieties

Treatment of PTSD

Workshop Conclusion &
Evaluation
Terminology

“Courage
Client
iscomes
resistance
putting
to fear,
oneself
mastery
of fear,the
notwhich
Patient––means
from
the
Latinunder
“Patiens”
protection
absence
fear”
ofwho
a– patron
Mark
Twain
means of“one
endures”
General Points about Anxiety:
Salkovskis (2008)

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Anxiety is normal
Feelings of Anxiety are
normal under threat
Physical changes are a
normal part of the
Anxiety response
Avoidance & Escape to
safety are normal
reactions to Anxiety


Anxiety only becomes a
clinical problem when it
is severe & persistent
Anxiety disorders are
exaggerations of normal
emotional reactions not
an “inherited brain
disease”
General Points about Anxiety:
Arden (2009, 2010)

We’re hard-wired as a species for
Anxiety

More than 25% of population suffer
from Anxiety



Core feeling in Anxiety is fear but can
also be concern, worry, apprehension,
panic, terror – gradations of Anxiety &
metrics
Never promise to get rid of patients’
anxiety rather to learn to cope &
manage it more effectively
Distinguish between Healthy Anxiety
which is a normal response to an
challenging situation (eg) exams,
interviews, public speaking etc

Fear-based memories encoded in the
amygdala are highly resistant to
forgetting

In Panic = escalating anticipation that
something terrible is happening

In GAD = fear is more free floating
that something is not quite right

In PTSD = fear is episodic, acute,
associated with flashbacks & triggers

In OCD = fear is that catastrophe is
about to happen & can be forestalled
by rituals or checking

In Phobias = fear is associated with
situations, sensations or animals or
objects
Types of Anxiety

Anxiety Disorder/GAD

Social Anxiety

Panic Disorder/Phobias

Post Traumatic Stress
Disorder (PTSD)

Obsessive-Compulsive
Disorder (OCD)

Existential/Bereavement
Anxiety

Life Stage Development
Anxiety

Health Anxiety
GAD



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Symptoms include having
trouble relaxing, easily
startled, poor concentration,
muscle tension, sleep
problems, headaches
Twice as many women suffer
GAD as men

Perfectionistic Standards

“Musturbation” (Ellis)
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Rigidity

Control obsession

Treatment = CBT/
Psychoeducation/
Relaxation/

Prognosis = guarded
Onset from middle
childhood on
Chronic condition with
situational triggers
Panic Disorder

Symptoms = Pounding heart, sweating
profusely, nausea, dizziness, weak knees,
frequency, dry mouth, feeling out of control etc

3% of population (USA)

Age of onset = 24 yrs

Treatment = CBT

Prognosis is good
OCD
Symptoms = Checking behaviour, Excessive
hand-washing, rituals, hoarding etc
 Age of onset = 19 yrs
 1% of population (USA)
 Treatment = CBT & SSRIs
 Prognosis is guarded
 High relapse rate
 ? More sinister psychopathology underneath

Phobias
Irrational fears of specific objects, places or
situations
 Multiple types of Phobias
 Age of onset = childhood on
 9% of population (USA)
 Treatment = Desensitization & anxiolytics
 Prognosis = good
 Can be Trauma element in genesis

Health Anxiety
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Constant fear about health issues or medical investigations
despite negative tests & reassurance from doctors –
hypochondria
Tend to interpret normal body changes as signs of illness
“I scarce ever read the account of any disease that I did not fancy myself
afflicted with” – Joseph Addison (1672-1719)
May include Body Image/Body Dysmorphia
3% of GP Consultations
No gender differences/ Adult onset
Children can have HA about their parents’ health
Treatment = CBT/ SSRIs/Anxiolytics
Prognosis = guarded
Health Anxiety : 7 Types
(Blenkiron, 2010)
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The Competitor – “Mine is much worse than other cases”
The Loner – Consults GP for a chat to fill the gap in her life
The Emergency – Out of hours crisis, no professional dares
refuse an urgent consultation
The Litigator – If something is wrong, then I’ll see you in court
The Proxy – Devotes her life to presenting her child’s/partner’s
or friend’s symptoms as a cover for own problems
The Eccentric – Internet downloads on alternative therapies and
spends large amounts on natural cures for which there is no
evidence
The Flatterer – Focus on those in training or very junior “You're
the only one I can talk to/who has ever understood me” which
may be true as the other professionals are tired of seeing her
Social Anxiety
Fear of social situations or meeting people
 Very common
 Age of onset = 13 or earlier
 7% of population meet DSM/ICD-9 criteria
 Treatment = Supportive/ Exposure/
Feedback/Self-Esteem work/ Social Skills
Development
 Prognosis = good
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PTSD
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Witnessing, experiencing Traumatic events which are
life-threatening
Affects both children & adults
Symptoms = numbness, nightmares, flashbacks,
reliving, avoidance, social withdrawal, irritability,
concentration & sleep difficulties, sense of
foreshortened future
Treatment = TFCBT, EMDR & SSRIs
NB = Relaxation Therapy & Non-Directive
Therapy are contra-indicated (NICE, 2006)
Prognosis = excellent for single event T
Existential/Bereavement Anxiety
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Anxiety/Panic associated with issues relating to Death,
Existence or Meaning of Life
Meaning making
No Gender differences
Age of onset = Teenage yrs on
Universal at different Life Stages but particularly MidLife
Key Life Questions arise – Who will I be? Who am I?
or Who was I?
Treatment = Supportive/Exploratory/ Logotherapy/
Existential Therapy
The Triune Brain (McLean, 1990) –
One Mind, Three Brains
Medical Conditions & Anxiety

Mitral Valve Prolapse
occurs in 5 – 15% of
General Population

Other conditions
include:

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Symptoms include chest
pains, breathlessness and
palpitations – symptoms
common in GAD
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Adrenal Tumours
Cushing’s Disease
Hypoglycaemia
Hypothyroidism
Meniere's Disease
Parathyroid disease
Post concussion
Medical Conditions & Anxiety

Anxiety symptoms can also arise from metabolic and
toxic effects of consuming or being exposed to
chemicals or compounds such as mercury, carbon
dioxide, barbiturates, benzodiazepines, Alcohol
withdrawal, and deficiencies in magnesium, vitamin
B12, potassium & calcium

Also asthma medications, nasal decongestant sprays,
many decongestants, steroids & caffeine

Some diabetics with hypoglycaemia may be unaware that
their anxiety symptoms are the result of low blood sugar
Breakfast

Skipping Breakfast contributes to –
Problem Solving
Working memory
Attention span
Concentration
Energy
Mood Swings
Stress Reactivity
Anxiety
Depression
Blood Sugar levels

Blood sugar levels below 0.5mgs per Mllltr can
lead to symptoms such as
Free floating anxiety
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Shakiness
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Light-headedness
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Irritability
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Rapid Heartbeat
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Concentration difficulties
Nutrition

After Breakfast, the food is absorbed in your
gastrointestinal tract

Amino acids & other nutrients such as vitamins &
minerals are carried thru the bloodstream to your brain

Enzymes convert amino acid precursors into
neurotransmitters.

Or the conversion takes place indirectly by causing
insulin to be released from your pancreas which draws
amino acids from your blood and tissues
Introduction to Cognitive
Behavioural Therapy in
the Treatment of Anxiety
Disorders
Dr Tim Dunne
Consultant/Registered Clinical Psychologist
Webster University, Geneva
5th & 6th November 2010
www.carlowpsychology.ie ©
th
6






November
Therapeutic Universals of
Treatment
Factors Determining Outcome in
Therapy
Therapist/Patient Differences in
Expectations
Core Concepts of CBT
Treatment approach
Development of CBT
Language & CBT

Resource Building

Case Formulation in CBT &
Case Study

CBT & Treatment of Anxiety,
Panic Disorder & Phobias

CBT Treatment of Life Stage.
Existential & Health Anxieties

Treatment of PTSD

Workshop Conclusion &
Evaluation
Life Stage Development Anxieties
L
E
Mid
Adu
Wh
Wh
Who
35
20’s
65
3 Phases of Therapy
UNCOVERING
DISCOVERING
RECOVERING
Therapeutic Universals

Most therapists get good
results consistently (Lambert
& Baley, 2002)

Therapists are poor judges of
their own successes/failures
(Arden, 2010)

Patients who drop out do so
because they have met their
goals (Pekarik, 1992)

Therapy can and does hurt
people (Lambert & Ogles,
2004)

Different schools of Therapy
are about equally effective
(Fonagy & Roth, 1996)

40% of patients would get
better without therapy
(Andrews & Harvey, 1981)
Therapeutic Universals

Who the Patient is, is the
most salient factor affecting
outcome (Lambert, 2004)
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Empathy, Warmth &
Positive Regard are central to
success of whatever school
of Therapy (Fonagy & Roth,
1996)

Therapeutic Relationship
(Alliance, Therapist’s
empathy & consensus on
goals) is crucial to success
(Norcross, 2002)

Therapist’s credibility, skill,
empathic understanding &
affirmation of patients,
capacity to engage with Pts,
focus on their problems
(Orlinsky et al, 1994)

Successful repair of ruptures
to the therapeutic alliance
(Norcross, 2002)

Dual Process in Therapy –
Learning and Unlearning
going on at the same time
Factors Determining Outcome in
Therapy (Lambert, 2006)
Technique
5%
Therapist
Factors
15%
Common
Factors
40%
Patient
Factors
40%
Therapist/Patient Differences
(Arden, 2009, 2010)

Therapists typically think
that more sessions will
be required than patients
do

70% of Pts said that they
wanted 10 sessions or
fewer

50% of Pts expected 5
sessions or less

Most patients seek
advice, problem
definition, problemsolving and lots of
therapist interactivity

70% of change occurs by
the 7th session

“Most patients want it
short, sweet and
effective” (Arden)
Historical Development of CBT

Behaviourism (Pavlov, Watson & Skinner 1900 – 1930s)
Behaviour Therapy (Wolpe, 1950 – 1960s)
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Rational Emotive Therapy (Ellis 1970s)
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MBCBT
Cognitive Therapy (Beck, 1980s)
TFCBT
DBT
Core Concepts of CBT
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Cognitive – refers to all our conscious mental
events or processes such attitudes, ideas
Behaviour
– refers to what we do & what we
Therapy
– refers
to abeliefs,
particular
approach used
impressions,
images,
memories,
avoid especially Safety Seeking behaviours
to
deal with abeliefs,
problem
perceptions,
assumptions, values,
attention, reasons etc
Core Concepts of CBT

Our thoughts influence our emotions which in turn influence
behaviour – what we think affects what we feel and do.

It is not what happens to us in life that is important but how we
chose to interpret it.

“There is nothing either good or bad but thinking makes it so” – Hamlet,
Shakespeare

“Men are not disturbed by events, they are disturbed by the interpretation of
which they make of them” – Epictetus (50 – 138 AD)
Core Concepts of CBT
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Psychoeducation / Information

Mindfulness including Breathing
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Cognitive Triad = Negative view
of Self, Current Experience & the
Future
Cognitive Distortions
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Exposure/Desensitization &
Cognitive Restructuring
Antecedent – Trigger Interpretation - Danger

Behaviour – What is it exactly we
do or don’t do/avoid

Consequences –
Feeling/Emotion

Recordings of Thoughts/Feelings

Underlying Beliefs / Assumptions
Relapse Prevention
NATs – Negative Automatic
Thoughts
Compassionate Mind
Core Concepts of CBT

Beliefs – I’m
Odd/Weird/Weak/
Stupid/Boring/
Unattractive/Useless

Assumptions = Rules for living
which develop early in life,
possibly even before
language/speech

There’s no hope for me
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What's the point?
I have to make other people
like me/ happy

I’m damaged goods

You must always obey the rules

It’ll always be like this

Others should know how I feel

It’s all my fault

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I’m Unlovable
Its my fault if the conversation
lags

I don’t deserve love etc
Core Concepts of CBT

Focus on Thoughts,
Feelings & Behaviours

Defines Problems &
Goals

Formulation

Uses evidence

Collaborative

Structured

Encourages Self-Help

Homework

Tests out new ideas &
behaviours

Measures & Records
Core Concepts of CBT

NATs Hierarchy -

Responsibility / Blame

Safety / Danger

Choice / Control

Self-defectiveness
Basic Assumptions
(Janoff-Bulman,1992)

The World is Benevolent

The World is Meaningful

The Self is Worthy

Bad Things don’t happen to Good People
General Principles of CBT

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Thorough Behavioural
Assessment before Treatment
begins
Main goal of CBT is to help
Patients bring about desired
changes in their lives
Treatment focuses on new
learning and generalization
outside the Therapy room
Problem-solving is an important
element in CBT

All aspects of Therapy are made
explicit to Patient

Collaborative effort between
Patient & Therapist

CBT is time-limited with
explicit goals

Emphasis on the Here & Now

Patient is helped to recognize
patterns of 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,
Catch
all typespeaking
words (eg) “Upset/Awful/Terrible”
emotionally

Taking Responsibility – encourage use of “I” rather than accept
“You/One”

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Alexithymia = “Emotional Illiteracy” – person does not have the
words
express feelings / emotions – Feelings list
SocratictoQuestioning

Sensations V Feelings V Emotions
Resource Building
Very important to develop
Patient’s resources/coping
skills for Affect Regulation

Boundary Development

Compassionate Mind

Deep Breathing
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Mindfulness/Present Focus
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Safe Place exercise

Grounding
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Hand on Heart

Challenging your Thoughts

SUDS – Subjective Units of
Distress scale – 0 to 10

Re-framing

Normalizing the
feeling/sensation

Validating their experiences

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Healing Light exercise for
Pain Mgt
Formulation in CBT

“Formulation provides an hypothesis about a
patient’s difficulties which draws upon
psychological theory” – Johnstone & Dallos
(2006)

Its purpose is to relate all the patient’s
complaints to one another and explain how the
person developed these difficulties

It provides a plan of intervention based on
psychological processes & principles
Formulation in CBT

Draws on Cognitive &
Behavioural theory

Collaborative
Empiricism between Pt
& Therapist


CBT Formulations are
always provisional
Formulation provides a
framework for
intervention

Good therapeutic
relationship with Pt is
necessary in CBT

Focus on current
problems and mutually
agreed goals

CBT Formulation is not
Diagnosis under another
name
Formulation in CBT

Presenting Issues – in terms of Emotions, Thoughts &
Behaviours

Precipitating Factors – Proximal External & Internal triggers for
the PIs

Perpetuating Factors – Internal & External factors that maintain
the PIs

Predisposing Factors – Distal External & Internal factors that
increased Pt’s vulnerability to current PIs

Protective Factors – Pt’s Resilience & Strengths and Social
Supports available
Case Study

Read Case Study

Use Case Formulation sheet

In Groups discuss your individual findings and
any differences which may have arisen between
you in terms of your Formulation and Why etc

How does this CBT approach compare with
other therapeutic models?
CBT Treatment of
Anxiety (GAD & Social), Panic & Phobias

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Agree Treatment Goals/Manage
Pt’s Expectations
Case Formulation following detailed
Behl Assessment
Resource Building – see earlier slide
Deep Breathing
SUDs /Log Recording of
Anxiety/Stress
Safe Place exercise
Boundary Development
Mind your Language!
Thought Stopping
Ruminating V Reflecting
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Normalize body sensations
Psychoeducation on Anx/PAs –
Hand-outs
Information on
Flight/Fight/Freeze Response
Compassionate Mind/ Mindfulness
Use Stories whenever possible &
appropriate
Identify NATs
Identify Beliefs/Assumptions
What's the worst that can happen?
“Futurizing/Pasturizing” (Dunne)
“Musturbation” (Ellis)
CBT Treatment of
Anxiety, Panic & Phobias

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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