an introduc+on to cbt for anxiety · anxiety disorder (gad) stressful life events or personal...
TRANSCRIPT
AnIntroduc+ontoCBTforAnxiety
AndrewGrimmer25thJune2016
“Thealarmisworsethanthefire”(Beck,1976)
Aims
• Toassessanxietyanditsimpact• Toformulatearangeofanxietydisorders• Tolearnandprac+seCBTinterven+onsforanxiety– CBTforanxietyisatleastasmucha“doing”therapyasa“talking”therapy
• I’msorry,wewon’tbeaOemp+ngtocoverPTSD
Self-evaluate
• Inpairs,pleasediscuss:
– WhatdoIalreadyfeelconfidentaboutintermsofmyunderstandingofCBTforanxiety?
– InwhatwayswouldIliketodevelopmyknowledgeandskillsinthisworkshop?
Terminology(Clark&Beck,2010)• Fear:aprimi+veautoma+cneurophysiologicalstateofalarm
involvingthecogni*veappraisalofimminentthreatordangertothesafetyandsecurityofanindividual
• Anxiety:acomplexcogni+ve,affec+ve,physiologicalandbehavioralresponsesystem(i.e.threatmode)thatisac+vatedwhenan+cipatedeventsorcircumstancesaredeemedtobehighlyaversivebecausetheyareperceivedtobeunpredictable,uncontrollableeventsthatcouldpoten+allythreatenthevitalinterestsofanindividual
• Worry:arepe++vethoughtprocessoftryingtofindcertaintyinuncertainsitua+onsbyforeseeingandplanningforeveryconceivableoutcomethatcreatesthefeelingsandemo+onsexperiencedasanxiety
• Panic:overwhelmingterrorinthefaceofimminent,catastrophicdanger
Normalvs.abnormalanxiety?• Cogni+ons:Isthefearoranxietybasedonafalse
assump+onorfaultyreasoningaboutthepoten+alforthreatordangerinrelevantsitua+ons?
• Func+oning:Doesthefearoranxietyactuallyinterfereintheperson’sabilitytocopewithaversiveordifficultcircumstances?
• Persistence:Istheanxietypresentoveranextendedperiodof+me?
• Triggers:DoestheindividualexperiencefalsealarmsorpanicaOacks?
• Hypersensi+vity:Isfearoranxietyac+vatedbyafairlywiderangeofsitua+onsinvolvingrela+velymildthreatpoten+al?
Comorbidity
• Depression:76%life+me-associatedwithamorepersistentcourseofdisturbance,greatersymptomseverity,andgreaterfunc+onalimpairmentordisability
• Substanceuse:2-4xmorelikely:reciprocalandinter-ac+nginfluences(notjustself-medica+ng)->increasedsuiciderisk
• Otheranxietydisorders:especiallyGAD
Context
• Widespread:25-30%life+meprevalence• Women>men:2:1• Culture:apprehension,worry,fear,andsoma+carousalarecommoninallculturesbutvaryinexpression
• Chroniccourse;majorityhaveonsetinchildhood/adolescence
Allofus(inonewayoranother)
• Writedownonapieceofpaperwhatfrightensyouormakesyouanxious
• Putitinthe“hat”• I’llwritethemupbutyouwon’tbeaskedtoiden+fyyourcontribu+on
LeDoux’sparallelneuralpathwaysinauditoryfearcondi+oning
Memory,reasoningandjudgment
Psychophysiology:SNS• Sympathe+cnervoussystem(SNS)ac+va+on:hyperarousal
symptoms– constric+onoftheperipheralbloodvessels,– increasedstrengthoftheskeletalmuscles,– increasedheartrateandforceofcontrac+on,– dila+onofthelungstoincreaseoxygensupply,– dila+onofthepupilsforpossibleimprovedvision,– cessa+onofdiges+veac+vity,– increaseinbasalmetabolism,and– increasedsecre+onofadrenalineandnoradrenalinefromtheadrenalmedulla
Psychophysiology:PNS• Parasympathe+cnervoussystem(PNS):conserva+on-withdrawalsymptoms– tonicimmobility,– dropinbloodpressure,– fain+ng,– decreasedheartrateandforceofcontrac+on,– constrictedpupils,– relaxedabdominalmuscles,and– constric+onofthelungs
Features:physiological(1)Increasedheartrate,palpita+ons;(2)shortnessofbreath,rapidbreathing;(3)chestpainorpressure;(4)chokingsensa+on;(5)dizzy,lightheaded;(6)sweaty,hotflushes,chills;(7)nausea,upsetstomach,diarrhoea;(8)trembling,shaking;(9)+nglingornumbnessinarms,legs;(10)weakness,unsteady,faintness;(11)tensemuscles,rigidity;(12)drymouth
BiologicalconcomitantsofanxietyBiologicalfactors Cogni*vesequelaeElevatedtonicautonomicac+va+on Increasedsalienceofthreat-related
s+muliSlowerhabitua+onrate SustainedaOen+ontothreatDiminishedautonomicflexibility ReducedabilitytoshimaOen+onGene+cpredisposi+onfornega+veemo+onality
Hypervalentschemasofthreatanddanger
Subcor+calfearpoten+a+on Preconsciousfears+mulusiden+fica+onandimmediatephysiologicalarousal
Extensivecor+calafferentandefferentpathwaystosubcor+calemo+on-relevantcircuitry
Cogni+veappraisalandmemoryinfluencefearpercep+onandmodulatefearexpressionandac+on
Features:cogni+ve(1)fearoflosingcontrol,beingunabletocope;(2)fearofphysicalinjuryordeath;(3)fearof“goingcrazy”;(4)fearofnega+veevalua+onbyothers;(5)frighteningthoughts,images,ormemories;(6)percep+onsofunrealityordetachment;(7)poorconcentra+on,confusion,distrac+ble;(8)narrowingofaOen+on,hypervigilanceforthreat;(9)poormemory;(10)difficultyinreasoning,lossofobjec+vity
Cogni+vetriad
• Worldisdangerous• Selfisvulnerableandhelpless• Futureisuncertain
Features:behavioural
(1)avoidanceofthreatcuesorsitua+ons;(2)escape,flight;(3)pursuitofsafety,reassurance;(4)restlessness,agita+on,pacing;(5)hyperven+la+on;(6)freezing,mo+onless;(7)difficultyspeaking
Features:affec+ve
(1)nervous,tense,wound-up;(2)frightened,fearful,terrified;(3)edgy,jumpy,jiOery;(4)impa+ent,frustrated
Fiveaspectsmodel:Padesky&Mooney
Thoughts
Behaviour Emo+ons
Physicalsensa+ons
Environment
Woozles?
Assessment:what’stheproblem?• 5Ws
– What– When– Where– Why– Withwhom
• FIDO– Frequency– Intensity– Dura+on– Onset
• Impact– Occupa+onal/financial– Domes+c/self-care– Social– Personalinterests– Rela+onships
• Features– Physiological– Cogni+ve– Behavioural– Affec+ve
Videoexercise
• DrWrightandGina:– AssessingSymptomsofAnxiety
Smallgroupexercise
• Ingroupsoffive– ComparewhatyoulearnedaboutGina– Discusswhatelseyouthinkitwouldbehelpfultoknow
ADSMs
• GAD-7:generalanxietymeasure• SPIN(SocialPhobiaInventory):socialanxiety• OCI(ObsessiveCompulsiveInventory):OCD• PDSS(PanicDisorderSeverityScale):Panicdisorder
• MI(MobilityInventory):Agoraphobia• PSWQ(PennStateWorryQues+onnaire):GAD• HIA(HealthAnxietyInventory):Healthanxiety
Func+onalanalysis:“onethingleadstoanother”
• Boxes:content• Arrows:process
Antecedents(externalandinternal)
Behaviour(safety-seeking
and/oravoidant)
Consequences(reinforcement)
Two-factortheory(Mowrer)
• Acquisi+on:classicalcondi+oning• Persistence:nega+vereinforcement
Trauma+cevent(classical
condi+oning)Avoidance Nega+ve
reinforcement
Two-factortheory:problems
1. Somes+muliproduceafear-responsemoreeasilythanothers(snakesvs.flowers)
2. Omennorecalloftrauma+cevent3. Non-associa+velearning:vicarious/
informa+onal4. Notalltrauma+ceventsproduceacondi+oned
fearresponse5. Somephobiasaremorecommonthanothers
(spidersvs.den+sts)
Fearmodule(Öhman&Mineka,2001)
• “Arela+velyindependentbehavioral,mental,andneuralsystemthatisspecificallytailoredtohelpsolveadap+veproblemsencounteredbypoten+allylife-threateningsitua+onsintheecologyofourdistantforefathers”– Selec+velysensi+zed:preferen+alaccesstocertaincues/s+muli
– Automa+city:preconsciousac+va+on– Encapsula+on:impenetrabletoconsciousinfluences– Specificneuralcircuitry:amygdalapriori+sa+on
Genericcogni+vemodel(Clark&Beck,2010)
Anxietyfeedbackloops
1ryappraisal:threat2ryappraisal:vulnerability
Situa+on/trigger
PhysicalEmo+onalCogni+veeffectsBehaviour
Gene
ralises Sensi+ses
FocusesConfirms
Amplifies
Anxietyequa+on
Anxiety=ProbabilityxAwfulness
Coping+Rescue
Salkovskisetal,1998)
Trigger: hearing a news item about cancer!
Roleplay
• Intrios:– Client:roleplayananxiousclientthatyouhaveworkedwith(ormakeoneup)
– Therapist:exploreaspecificrecentincidentofanepisodeofanxietyusingtheanxietyequa+on/feedbackloops
– Observer:makeanoteofwhatthetherapistelicitsagainsteachofthecategories
Cogni+vespecificityAnxietydisorder Threatenings*mulus Coreappraisal
Panicdisorder(withorwithoutagoraphobia)
Physical,bodilysensa+ons
Imminentfearofdying(“heartaOack”),losingcontrol(“goingcrazy”)orconsciousness(fain+ng),havingfurtherpanicaOacks
Healthanxiety Physical,bodilysensa+ons
Fearofhavingalife-threateningillness
Generalizedanxietydisorder(GAD)
Stressfullifeeventsorpersonalconcerns
Fearofpossiblefutureadverseorthreateninglifeoutcomes
Socialphobia Social,publicsitua+ons
Fearofnega+veevalua+onfromothers(e.g.,embarrassment,humilia+on)
Obsessive–compulsivedisorder(OCD)
Unacceptableintrusivethoughts,images,orimpulses
Fearoflosingmentalorbehavioralcontrolorotherwisebeingresponsibleforanega+veoutcometoselforothers
Anxietycarousel• Specificphobia• Blood-injury-needlephobia• Panicdisorder• Agoraphobia• Emetophobia• Socialanxietydisorder• Generalisedanxiety
disorder• Obsessivecompulsive
disorder• Bodydysmorphicdisorder• Healthanxiety
• Youhave5minutes(approx)to:– Iden+fythetrigger(s)– Iden+fythecoreappraisalsofthreatandvulnerability
– Iden+fyavoidanceandsafetybehaviours
– Checkouttheimpact
Generalprinicples
• Agenda:priori+sing• Feedback:clarifyingunderstanding• Pacing:workingattheclient’sspeed• Collabora+on:coopera+ngasateam• Emo+on:helpingtheclienttoregulatedistress,modellingthatanxietyisunpleasantbutnotdangerous
Guideddiscovery
• Informa+onalques+ons:exploreallfacetsoftheproblem(5areas:boxesandarrows)
• Summarise:helptheclientretainandfocusonrelevantinforma+on
• Expressempathy:demonstrateyouunderstandandappreciatetheclient'sdistress
• Synthesise:elicitandconsolidatelearning
Anxiety-specifictreatmentprinciplesCogni*vetenets Treatmentimplica*ons
Exaggeratedthreatappraisals Recalibratethreat;increasetoleranceforriskanduncertainty
Heightenedhelplessness Increaseself-confidencetodealwiththreatanduncertainty
Inhibitoryprocessingofsafety Improveprocessingofsafetycues;reducesafety-seeking
Impairedconstruc+veorreflec+vethinking
Cogni+verestructuringskills(controlledefforxulthinkingskills);tackleworry
Automa+c(1ry)andstrategic(2ry)processing
Behaviouralandexperien+alexercises
Self-perpetua+ngprocess Correctmisinterpreta+onsofanxietysymptoms
Monitoring• Diaries:– thinkaboutwhatyouwanttheclienttolearn
Day/*me Anxiety(0-10)
Thoughts,concernsorworries
Behaviour(avoidanceorsafety-seeking)
Consequences(+&-)
Weds5pm 7/10 WhatifImessupatwork–I’lllook
likeanidiot
WorryPhonedMum
Worrymadeproblemseemevenbigger
Feltreassured,onlylasted30
minutes
Understanding• Formula+ng– Idiosyncra+cformula+on:
• usetheanxietyequa+onforgenericpresenta+ons;checkoutidiosyncra+cmodelsforspecificdisorders
– Cogni+vera+onale:• makesureyouunderstandtheroleofanxiousappraisal(threat/vulnerability)andavoidance/safetybehaviours
• Psychoeduca+on– Anxietysymptoms:
• prac+seexplainingfight,flight,freezeresponse
Exposure:prolongedandrepeated• Basedonprincipleofhabitua+on– Graded:constructahierarchybasedonSUDs(subjec+veunitsofdistress)–startwithatleast30%
– Responsepreven+on:inhibitresponseun+lanxietydiminishesbyatleast50%
– In-session:prac+seexposurein-session– Invivo:accompanyclientson“fieldtrips”– Interocep+ve:panicinduc+on(seeCCIPanicSta+ons)– Imaginal:
• Firstperson,presenttense,worstcasescenario• Copingimagery:walkthroughthefrighteningsitua+oninimagina+on
www.getselfhelp.co.uk © Carol Vivyan 2010. Permission to use for therapy purposes. www.get.gg
When we avoid situations because we get too anxious or distressed, if we think about or find ourselves in those situations, our anxiety rises sharply, stays on a level for a while, then slowly starts to decrease gradually….
Length of Time
If we didn’t avoid the situation, just do it anyway and stick with it, then the first time will be the worst. Each time after that, we’ll find that we won’t be quite so anxious as the time before, and the anxiety will start to pass a little quicker than the previous time, so the diagram might look something like:
Length of Time
Level of D
istr
ess
Level of D
istr
ess
Habitua+on
Behaviouralexperiments• Tes+ngassump+ons:– “if…then...”proposi+onalstatements
Thoughttobetested:“If…then...”
Experiment:whatwhen,where,withwhom
Predic+on(ifthoughtistrue)
Obstacles/barrierstoovercome Solu+ons/strategiestoovercomebarriers
Whathappened? WhatdidIlearn(aboutthethoughttobetested)?
VerbalreaOribu+on:TheoryAvs.TheoryB
Theory A Theory B
Theory BTheory A
PSYCHOLOGYT LS
The problem is ...
Evidence
What do I need to do if Theory A is true? What do I need to do if Theory B is true?
Evidence
The problem is worry that ...
http://psychology.tools
TheoryAvs.TheoryB:healthanxiety
Theory A Theory B
Theory BTheory A
PSYCHOLOGYT LS
The problem is ...
Evidence
What do I need to do if Theory A is true? What do I need to do if Theory B is true?
Evidence
The problem is worry that ...
I have brain cancer I have brain cancer
I have these symptoms:HeadachesDizzinessVision goes blurry sometimes
Doctor tells me it is not cancerThe headaches are worse when I am stressedFocusing on my symptoms makes them worseReassurance makes my symptoms betterI’ve had these symptoms a long time andthey have not got any more serious
Go to the doctor and insist that they treat mestraight away - brain cancer is serious!
Learn how to deal with my worry
http://psychology.tools
VerbalreaOribu+on:P3RPlan(amerPadesky)
Predict:whatbadthingsmighthappenifyoudidthis?
Preparecopingresponses:whatcouldyoudowhenthishappens?
Prac+seyourresponses(when,where,how,withwhom)
Reflect:whathaveyoulearnedaboutyourvulnerability?
• Anexperimenttotestoutfearsandovercomeavoidance– Specifywhatyou’vebeenavoiding– Ratehowanxiousthethoughtofitmakesyoufeel(0-10)
Calming/refocusingtechniques• Physiological– Progressivemusclerelaxa+on– Breathingretraining
• Mindfulness:– defusingfromtheanxiousthought/experience:
• “TheawarenessthatemergesthroughpayingaOen+ononpurpose,inthepresentmoment,andnonjudgmentallytotheunfoldingofexperiencemomentbymoment.”JohnKabatZinn• quicksandmetaphor;demonsontheboat
• AOen+ontraining:AdrianWells
Worrystrategies• Worrystrategies– Worrydiary:
• Hypothe+calscenariovs.acurrentconcern• Makeaspecificpredic+on
– Worry+me:toteachthatworryiscontrollable• Setasideaspecificamountof+meeachdayforworrying• Ifyoudonotwanttouseyourworry+meforworrying,useitforsomethingelse
– Worrytree(plusproblemsolving):• IsthereanythingIcanusefullydo?• If“yes”whenshouldIdoit?• Letgoofworry
Intoleranceofuncertainty:DugasUncertaintyandchangeinbehaviourDate:
Descrip+onoftheac+onchosen:
Discomfortduringtheac+on
Thoughtsduringtheac+on
Observa+onsamerperformingtheac+on
Intoleranceofuncertainty:exampleUncertaintyandchangeinbehaviourDate:
Descrip+onoftheac+onchosen:Iwillcheckmye-mailonlytwiceperday(tocombatrepeatedchecking).
Discomfortduringtheac+on:IfeelterriblewhenIcan’tcheckmye-mail.Ifeelfeverishandnervous.Ireallywanttogocheckmye-mailrightnow.
Thoughtsduringtheac+on:IthinkI’mgoingtomisssomethingimportant.I’mafraidpeoplewillthinkI’mnotdiligentinmywork.AclientcouldhaveaproblemandIwouldn’tbeabletohelp.
Observa+onsamerperformingtheac+on:Thefirstdaywasverydifficult.Amerafewdays,Irealizeditwasge|ngeasierandtherewasnodramaorcatastrophe.
Worryques+ons• Whatareyouworryingabout?• Whatisitaboutitthatconcernsyou?• Whatistheveryworstthatcouldhappen?
– Andwhatmakesthatsoawful?• Whatistherealis+clikelihoodofitoccurring?
– Howmuchwouldyoubetonit?• Makeaspecificpredic+on(worryhatesspecifics)
– Howconfidentareyou(outof10)?– Howanxiousdoesthatmakeyoufeel(outof10)?
• Ifyourpredic+oncametrue,whatcouldyoudotodealwithit?– Howwoulditlookin5years?
• Whocouldyouturntoforhelp?– Howwouldtheyhelpyou?
• Isthereanythingyoucanorshoulddoaboutyourconcern?• Ifyes,whenshouldyoudoit?
Resources
• GetSelfHelp:www.get.gg• PsychologyTools:hOp://psychology.tools• TherapistAid:hOp://www.therapistaid.com• LivingLifetotheFull:hOp://www.ll}.com• CentreforClinicalInterven+ons:hOp://www.cci.health.wa.gov.au
• MoodGym:hOps://moodgym.anu.edu.au/welcome
Roleplay
• Intrios:– Client:roleplayananxiousclientthatyouhaveworkedwith(ormakeoneup)
– Therapist:chooseastrategybasedontheclient'spresenta+onandtryitout
– Observer:makeanoteofwhatthetherapistelicitsagainsteachofthecategories
Finalthoughts
• Inyouroriginalpairs:revisityouroriginalanswers– InwhatwaysdoIfeelmoreconfidentaboutmyunderstandingofCBTforanxiety?
– HowcouldIapplywhatIhavelearnedfromthisworkshopinmyprac+ce?
