Cognitive Behaviour Therapy for Anxiety

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2 Cognitive Behaviour Therapy for Anxiety Jodie Paget BSc Hons, PG Cert, PG Dip Associate Tutor CBT Skills

3 CBT is An action orientated psychotherapy that teaches individuals to identify, challenge, and replace their self-defeating thoughts and beliefs with healthier thoughts that promote emotional well-being and goal achievement. Men are disturbed not by things, but by the view which they take of them - Epictetus

4 CBT Model The basic CBT model proposes that every experience we have has specific thoughts (beliefs), emotions, physiological responses and behaviour associated with it.

5 Scenario You have been told you are losing your job How might you feel? Angry, Anxious, Depressed Happy? What would you need to think (and believe) about losing your job to feel each of the above?

6 How we feel emotionally gives us a very good insight into what we are thinking and the health of our thoughts. So feeling extreme anxiety accompanied by physical discomfort (headaches, nausea, IBS etc ) would suggest some unhealthy thinking is occurring. Healthy beliefs result in healthy emotional and behavioural responses.

7 What is Anxiety? CBT defines anxiety as an emotion, more specifically an unhealthy emotion. Unhealthy emotions always result from unhealthy thinking and most often produce maldaptive behaviour responses. Thought Process Overestimation of threat Underestimation of ability to cope Creates even more negative threat in ones mind Has task irrelevant thoughts Behaviours Withdraw from threat (Physically or mentally) To ward off the threat (by superstitious behaviour) To seek reassurance

8 Healthy Concern rather than Anxiety Anxiety= Overestimation of threat/danger Underestimation of coping + rescue factors Concern is viewed as a healthy emotion in that it is always associated with the following: Thoughts Views threats realistically Realistic appraisal of coping ability Does not create an even more negative threat in ones mind Has more task relevant thoughts than in anxiety Behaviours To face up to threat To deal with threat constructively

9 Anxiety Disorders There are many types of anxiety disorders we are covering: Panic Disorder Health Anxiety Social Anxiety Disorder

10 Safety Behaviour A behaviour engaged in that prevents catastrophe from occurring

11 Panic Disorder A panic attack is an abrupt surge of intense fear that reaches a peak within minutes, during which time 4 or more of a list of 13 symptoms occur. The attack appears to come out of the blue 2%-3% in adults and adolescents Females out number males by 2:1

12 Panic Attack Criteria 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. 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.

13 The Cognitive Model of Panic Internal/External Trigger Palpitation, shortness of breath Perceived Threat I can t breathe, I might faint ANXIETY (Panic) Catastrophic Misinterpretation I m going to die I m going to pass out and nobody will help Physical/Cognitive Symptoms My chest is getting tighter My heart is racing there is something wrong with it Avoidance and Safety Behaviours Pounding chest, dizziness, tunnel (What you did that prevented the catastrophe) vision, dry mouth Left the situation Never go out alone Take unnecessary medication Avoid exercising

14 Working with Panic Disorder Psychoeducation physiology of anxiety, triggers, and the maintenance cycle Theory A vs. Theory B Panic Diaries Identifying (and dropping) safety behaviours Induction of anxiety symptoms Fear Hierarchy - Behaviour Experiments Relapse prevention

15 Social Anxiety Disorder Intense, fear of social situations in which the individual may be scrutinized by others (FNE). Concerned that he or she will be judged as anxious, weak, crazy, stupid, boring, intimidating, dirty, or unlikable etc. The individual fears that they will act or appear in a certain way or show anxiety symptoms (blushing, trembling, sweating etc) that will be negatively evaluated by others. The individual will often avoid the feared social situations or endure them with intense fear. Avoidance can be extensive (e.g., not going to parties, refusing school) or subtle (e.g., over preparing a speech, diverting attention to others, limiting eye contact).

16 Contamination The Cognitive Model of Social Anxiety Disorder Social Situation Group Discussion Activates Assumptions I must not show signs of anxiety I must appear competent Perceived Social Danger (Negative Automatic thoughts) They think I am stupid They think I m anxious Safety Behaviours Not participate Sit at the back Not make eye contact Processing of Self as Social Object Self Conscious, image as bright red, is aware of own voice Somatic and Cognitive Symptoms Trembling, racing heart, dry throat, difficulty concentrating

17 How CBT works with Social Anxiety Disorder Psychoeducation The model, triggers Eliciting thoughts, and assumptions Eliciting safety behaviours and anxiety symptoms Disputing assumptions and challenging negative automatic thoughts (thinking errors) Behaviour experiments to test predictions Modifying self-processing in the moment (attentional training) Managing anticipatory anxiety (cognitive restructuring, distraction) Managing the post mortem (Assess the pros and cons of the post mortem, it s distorted nature then finally banning it)

18 Health Anxiety (Illness Anxiety Disorder) formerly Hypochondriasis Preoccupation with having or getting a serious medical illness Checkups often do not detect any medical problems however despite this the individual's anxiety comes from not the illness itself but rather the meaning and/or significance of the illness. If a symptom is present, it is often a normal sensation (e.g. dizziness), or a bodily discomfort not generally considered indicative of disease (e.g., belching). If a diagnosable condition is present, the anxiety and preoccupation are excessive and disproportionate to the severity of the condition Two Types of behaviour: Care Seeking and Care avoidant

19 The Cognitive Model of Health Anxiety Trigger Death of a friend/family member Negative Automatic Thoughts There is something terribly wrong with me, I must know what s wrong, I can t bear not knowing Cognitive Focusing on symptoms Discounting medical feedback Overemphasising the significance of symptoms Anxiety Behaviour Reassurance seeking Visiting the doctor Checking the internet Scanning for symptoms Avoidance Physiological Changes Increased arousal

20 How CBT works with Health Anxiety Explore evidence for disease fears Assess avoidance and safety behaviours Managing selective attention Explore alternative evidence for disease and develop alternative explanation for symptoms (Theory A and Theory B) Behaviour experiments to challenge misinterpretations (drop safety behaviours, avoidance, checking etc) Fear Hierarchy (exposure) Explore the role of reassurance seeking eventually dropping it Introduce rational responding to thoughts

21 Summary What is the danger? Appraise this realistically How will I cope with it, what are my rescue factors? How have I coped with similar situations? What are my transferable strengths? Engage in a problem solving mindset rather that circular worry Dispute your anxiety generating beliefs and develop balanced coping beliefs, practice behaving in accordance with these beliefs Develop a list of distraction methods/activities that work for you If you can behave productively DO IT! - Problem solving, generate three solutions, assess them accordingly - if this isn t possible use distraction (an activity that heavily engages your mind or your body If symptoms persist practice tolerating them, challenge your belief that they are UNBEARABLE

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