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COGNITIVE THERAPY OF ANXIETY DISORDERS

REVIEW OF ANXIETY DISORDERS


Generalized anxiety disorder Panic disorder Phobias Obsessive compulsive disorder PTSD ASD

General schema model of anxiety disorder


Learning experience

Danger schemas formed

Critical incident Schemas activated Negative automatic thoughts Behavioral response Anxiety symptoms Cognitive biases

Whats wrong with their information processing


Filtering (attending selectively to threatening stimuli) Discounting positives Undermining own ability to cope Access to threatening memories Projecting worst future scenarios

Disorder

Key diagnostic feature


Recurrent unexpected Panic attacks; at least One month of anticipatory Anxiety; avoidance Fear of social or performance situations Recurrent obsessions or compulsions (time/distress/impairmn)

Cognitive themes

Panic disorder

Social phobia

Obsessive compulsive Disorder

Generalized anxiety Disorder

Misinterpretation of anxious symptoms Concern about the consequences of panic Concern about appearing anxious before other, embarrassment in public Concern about consequences of obsessive thoughts/compulsive acts. Of no reduction of distress by compulsions. Excessive and Concern about the uncontrollable worry uncontrollability and about many events (6m) danger of worrying

Panic disorder: case formulation interview


Introduction: Im going to ask you about a recent typical panic attack so that we may begin to map out what happened. When was your most recent panic attack? 1. Thinking about just before you panicked, what was the very first thing that you noticed that indicated that you might panic? Was it a thought (Q3), a sensation (Q2), or an emotion (Q4)? 2.When you noticed that sensation what thought went through your mind? 3. When you noticed the thought how did that make you feel emotionally?

4. When you noticed that emotion what sensations did you have? 5. When you had those sensations what thought went through your mind? 6. How much did you believe (insert catastrophic misinterpretation) those thoughts at that time? 7. What happened to your anxiety when you thought that? 8. Did you do anything to lower anxiety? What was that? 9. Since you have developed panic do you focus attention on your body/thoughts?

1. Trigger

Response to trigger- thought Response to trigger-emotion 7.Panic Belief that I am dying

Response to trigger Sensory ampfcn

Safety behaviour/counters Anticipatory anxiety - behaviour

Panic disorder: treatment


Psycho education Exposure to internal cues (spinning in the chair, hyperventilating, swaying head from side to side) Cognitive restructuring decatastrophizaton Graded exposure to feared events (or usual activities that were being avoided) Practice in as many contexts as possible Talk about safety behaviours/ counters

Panic disorder: treatment

Behavioural (or largely behavioural) techniques Relaxation Imagery Breathing exercise Others

Cognitive restructuring

Goals of a patient with panic disorder (exposure)


"To travel alone by train to the city and return at peak hour" "To shop alone in the local supermarket and do the weekly shopping" "To go to the movies at night with friends and sit in the middle of the row"

Break up first goal into small, easy to do steps


Travelling two stops in an over-ground train, quiet time of day Travelling two stops in an over-ground train, peak hour Travelling one stop in an underground train, quiet time of day Travelling two stops in an underground train, peak hour Travelling five stops in an underground train, quiet time of day Travelling five stops in an underground train, peak hour

Plan and prepare before exposure


Use the progressive muscle relaxation, isometric or slow breathing exercises if possible before you go out. Perform all activities in a slow and relaxed manner. Give yourself plenty of time. Mentally rehearse your activity. For example, if you are traveling by train, mentally rehearse some coping statements to say to yourself as the doors close, as more people get on and so on. Monitor your breathing rate at regular intervals e.g., once every 5-10 minutes. You may use your slow breathing exercise to reduce your breathing rate if it is higher than it should be.

Do not leave a situation until you feel yourself to be calming down. Never leave the situation out of fear - face it, accept it, let it fade away and then either move on or return. If you do not do this you may interpret it as a failure and lose confidence. The longer you remain in a situation the calmer you will become and the faster you will overcome your fears e.g., staying for two hours in a shopping centre is better for you than going here for a total of two hours on four occasions. Congratulate and reward yourself for attempting or completing exposure tasks

Doubts about behavioral techniques or medication in treatment of panic disorder


Questions are being raised about use of medications, relaxation, imagery, or even distraction techniques in the treatment of panic disorder. (these may be used by patients as counters/safety behaviours/ escape behaviours) If we have to use the above techniques, we must repeat CBT sessions once these are discontinued.

Social phobia

Graded exposure

Social skill training Assertive training

Not for all

Obsessive compulsive disorder


Out, damned spot! Out, I say! One, two, why then tis time to dot. Hell is murky. Fie, my lord, fie! Yet who would have thought the old man to have had so much blood in him? .Wash your hands, put on your nightgown, look not so pale

OCD: common obsessions and compulsions

Contamination

Physical violence to self and others Images of loved ones dead Impulse to shout out an obscenity

Wash, check body for symptoms of disease. Ring doctor. Wont be alone with baby, seeks reassurance, hides knives. Counter imagination of same people alive Avoids social situations, asks others whether behaviour was acceptable in particular situation.

OCD: case formulation interview


Introduction: I am going to ask you about the last time you were distressed by an obsessional thought and you felt compelled to respond to it. 1. What was the thought/image/impulse that triggered you? 2. When you had that thought how did you feel emotionally (eg anxious /scared/ depressed)?

3. Do you believe these thoughts mean something? What is the worst they could mean? How much did you believe that at the time? 4. Did you do anything to stop from happening? Did you do anything to stop yourself doubting? Did you try to prevent feeling anxious? (what did you do?) 5. Do you believe that you must behave in certain ways in order to remain safe and stop bad things from happening?

1. Trigger thought/image/impulse What does the trigger personally mean to the patient?

Amount of distress it caused

Did he try to fight back rationally

Did he give in to compulsive acts?

Treatment of OCD: rationale of ERP

With exposure and ritual completion

With exposure and response prevention

*ERP
Exposure with positive self talk No bland reassurance Ask patient to treat this as a behaviour experiment. Usually lasts two hours. Modelling

Principles of ERP
Limits will be set on your ritualized behaviour Graded exposure You will not use counters Family members will not be enlisted to carry out your rituals.

More cognitively oriented strategies (besides ERP)


Over importance of thoughts Over estimation of threat/all or nothing thinking Thought - action fusion Difficulty handling doubt and uncertainty Over responsibility Emotional reasoning

Ask yourself Where is the evidence? Even if internal self talk appears logical and accurate, are the feared consequences really as awful or catastrophic as the OCD is trying to make them out to be? Reduce all or nothing thinking. Do a cost benefit analysis.

But beware

Is the CT turning into one big repetitive self reassurance ritual? Then throw the CT out of the window. Use of CT strategies during flooding style ERP tasks can dilute the intensity of the exposure task and thereby reduce potential for habituation gains. Is your self talk becoming another obsession? Then abandon it. The same questions have been raised about thought stopping also, though it is still used effectively by many therapists.

GAD: Psycho education

Imaginary exposure

Relaxation therapy

THANK

YOU

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