five-factor (area) model for anxiety disorders: an

Five-factor (area) model for Anxiety

Disorders: An evidence-based

pragmatic psychological treatment

Sammy Cheng, Ph.D.

Specialist in Clinical Psychology

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� Methods: Methods: Methods: Methods: 5,719 Chinese adults aged 16–75 years in Hong Kong population, using the Chinese Revised Clinical Interview Schedule

� Results: Results: Results: Results: The weighted prevalence estimate for any past-week CMD was 13.313.313.313.3 %%%%, , , , with mixed anxiety and depressive disorder being the most frequent diagnoses. Among individuals with CMD, only 26262626 %%%% had consulted mental health services in the past year; less than 10less than 10less than 10less than 10 %%%%consulted general practitioners or family physicians.


Different types:

� Specific Phobias

� Social Phobia

� Panic Disorder

� Agoraphobia

� Generalized Anxiety Disorder (GAD)

� Obsessive-Compulsive Disorder (OCD)

� Post-Traumatic Stress Disorder (PTSD)


Two main strands of treatment:

1. Medications (e.g. SSRIs)

2. ‘Talking Therapies’ such as Cognitive Behavioral Therapy (CBT)

The best effects are seen when medications and The best effects are seen when medications and The best effects are seen when medications and The best effects are seen when medications and CBT are combined.CBT are combined.CBT are combined.CBT are combined.


� A mixture of cognitive and behavioral techniques

that link a person’s environment, thoughts, feelings,

behaviors and physical reactions

� Cognitive techniquesCognitive techniquesCognitive techniquesCognitive techniques: address “unhelpful” thoughts

that increase anxiety

� BehavioralBehavioralBehavioralBehavioral techniquestechniquestechniquestechniques: address “unhelpful” behaviors

that increase anxiety in the long run


1. Focus on current problems current problems current problems current problems of relevance to

the patient;

2. Delivery built on effective relationship effective relationship effective relationship effective relationship

with practitioner;

3. Psychoeducational form of psychotherapy

for one to learn new skills of selfnew skills of selfnew skills of selfnew skills of self----

managementmanagementmanagementmanagement for everyday life practice;


4. Clear model with strong evidencemodel with strong evidencemodel with strong evidencemodel with strong evidence

◦ Based on learning theories, anxiety disorder is

learnt and can be unlearnt by CBTcan be unlearnt by CBTcan be unlearnt by CBTcan be unlearnt by CBT

◦ Findings of neuroimaging give strong evidence

of neuroneuroneuroneuro----biological changes after CBTbiological changes after CBTbiological changes after CBTbiological changes after CBT

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Neurobiological Changes Associated with CBT J Neuropsychiatry Clin Neurosci 21:2, Spring 2009

Anxiety

Disorder

Neuro-

imaging Neuroimaging Findings after CBT

Spider phobia fMRIReduced activation of dorsolateral prefrontal cortex and parahippocampal

gyrus regions.

Spider phobia fMRIAbsence of activation of the anterior ventral insula and no difference from the

healthy control subjects

Social phobia PETReduced activities at right temporal lobe regions, amygdala, hippocampus,

rhinal activity, periamygdaloid

PTSD fMRI

Increased activation of left posterior, anterior medial temporal gyrus and

posterior cingulate gyrus activation of the posterior cingulate, medial frontal

gyrus, posterior cingulate activation, medial frontal gyrus, and left posterior

medial temporal gyrus

OCD PET Decreased activation of right caudate nucleus

OCD PET Decreased activation of right and left caudate nucleus

OCD PET Decrease in the activation of the frontal orbital cortex.

OCD fMRI Decreased activation in frontal orbital cortex.

Panic PET Decreased activation in left prefrontal, in right temporoparietal and occipital

regions.

Panic PETDecreased metabolism at right hippocampus, left ventral anterior cingulate

cortex, decrease in metabolism at right hippocampus, left ventral anterior

cingulate cortex, uvula, and pyramid of the left cerebellum and pons

CBT (ERP) reduces over-activity of frontal orbital and caudate nucleus regions in OCD patients

Orbital frontal

and right orbital frontal

Neuro-cognitive activities

in orbital frontal cortex

increased with

•Excessive swearing

•Hypersexuality

•Poor social interaction

•Pathological gambling

•Drug & alcohol abuse

•Poor empathy

•Frontatemporal dementia


OCD: OCD: OCD: OCD: learnlearnlearnlearn the fearthe fearthe fearthe fear

� Association between neutral stimuli/ thought/ situation & anxiety responses (C.C.)

� Reduce distress by ritualizing or avoidance: +ve & -ve reinforcement (Op.C.)

� Neurobiological deficits: hyperactivity in caudate nucleus, orbitofrontalcortex, cingulate gyrus

CBT (ERP): CBT (ERP): CBT (ERP): CBT (ERP): unlearn the fearunlearn the fearunlearn the fearunlearn the fear

� Exposure: habituate fearful stimuli with decrease in anxiety or distress; extinction (C.C.)

� Response prevention(extinction, Op.C.) �fear reduction

� Reduced hyperactivity in caudate nucleus,orbitofrontal cortex, cingulate gyrus


Significant time ××××

Treatment interactions were found in amygdalawith decreases both in brain structure (gray matter volume) and function (blood–oxygen level dependent, BOLD) responsivityafter CBT.


Rationale:Rationale:Rationale:Rationale:

� Evidence-based psychological interventions (Cognitive Behavioral Therapy, CBT) (Cognitive Behavioral Therapy, CBT) (Cognitive Behavioral Therapy, CBT) (Cognitive Behavioral Therapy, CBT) can be effective treatments for anxiety disorders. They are recommended first-line treatments in preference to pharmacological treatment. Healthcare professionals should usually offer or refer for the least intrusive, most effective intervention first, in line with the stepped-care approach set out in the NICE guidance.


1.1.1.1. Few experienced specialists Few experienced specialists Few experienced specialists Few experienced specialists for CBT services

2.2.2.2. Complicated models and jargons Complicated models and jargons Complicated models and jargons Complicated models and jargons for specific

anxiety disorders limit an efficient delivery of

training to clinicians and treatment to patients

3.3.3.3. Jargons: Jargons: Jargons: Jargons: negative automatic thoughts, schemata,

dysfunctional assumptions, faulty information

processing, dichotomous thinking, selective

abstraction, magnification, minimization and

arbitrary inference


� Complicated Complicated Complicated Complicated models models models models for specific anxiety disorders


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1. Situation

2. Thoughts

3. Behaviors

4. Feeling

5. Physical reaction



Negative

Catastrophic results

Dangerous

Avoidance behaviors

Safety behaviors

Fear

Anxious

Depressed

Heart pounding

Feeling hot

Sweaty, Shakiness

Headache, Stomach pain

Nausea

Situation


Thoughts

Feeling

Behaviors

Physical

reaction

5-factor model for

Anxiety Disorder

Reduce

unhelpful

thinking

Slow down

physical

reaction

Reduce

unhelpful

behaviors

My car will fall from

bridge. I am going to

die

Stop the car away

Drive another way next time

Fear

AnxiousHeart pounding

Feeling hot

Sweaty, Shakiness

Headache, Stomach pain

Nausea

Situation


Thoughts

Feeling

Behaviors

Physical reaction

Drive near a bridge5-factor model for

Agoraphobia

Cognitive

restructuring

Exposure exercise

Behavioral experiments

Calm

breathing

I have the heart

attack and going to

die

Try to escape and leave the

market. Call for help

Go to AED

Intense fear

AnxiousHeart pounding

SOB, faint

Situation


Thoughts

Feeling

Behaviors

Physical reaction

In a crowded market5-factor model for

Panic disorder

Cognitive

restructuring

Interoceptive exposure

Behavioral experiments

Calm

breathing

I am contaminated

and must wash the

hands

Wash hands repeatedly

Put of glove

Ask family to clean dirt

Distressed

AnxiousSweating

Muscle tension

SOB

Situation


Thoughts

Feeling

Behaviors

Physical reaction

Touch dirt on floor5-factor model for

OCD

Cognitive

restructuring

Exposure with response

prevention

Calm

breathing

I will embarrass myself.

I don’t know what to say.

I look stupid in front of

others

Avoid social contact

Self absorb and conscious

Remain mute in interactions

Leave the scenario

Tense, worried

AnxiousBlushing

Sweating

Muscle tension

SOB

Situation


Thoughts

Feeling

Behaviors

Physical reaction

Meet a stranger in work5-factor model for

Social Phobia

Cognitive

restructuring

Assertiveness training

Modeling

Behavioral experiment

Calm

breathing

I will be hit by car again

The car is rushing to me

The driver ruined my life

Cross road with others

Avoid to leave home

Drinking to numb self

Terrified

Fearful

Anxious

Angry

Trembling

Poor sleep

Sweating

Muscle tension

SOB

Situation


Thoughts

Feeling

Behaviors

Physical

reaction

Walking near the road5-factor model for

PTSD

Cognitive

restructuring

Exposure exercise

EMDR

Calm

breathing

I can cause my many big

troubles

I cannot manage it

Mentally ruminate the

problems (worrying)

Fearful

Anxious

Depressed

Trembling

Poor sleep

Muscle tension

SOB

Situation


Thoughts

Feeling

Behaviors

Physical

reaction

Minor problem in workplace5-factor model for

GAD

Cognitive restructuring

Detached mindfulness

Postponement of worry

Distraction

Muscle

relaxation

Cognitive

Psychoeducation

Identify –ve thoughts

Thought diary

Modify –ve thoughts

Behavioral

Distraction

Breathing control

Behavior experiment

Exposure (in vivo)

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Cognitive

Self-talk statement

Worry time log

Mindfulness

Problem solving

Behavioral

Cued relaxation

Imagery exposure

Activity schedule

Role play/

modeling

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� Integrate patient’s information into 5-factor

model

� Associations among –ve thoughts, avoidance,

affect, physical responses

� Normalize

� Intro tx strategies:

◦ Cognitive restructuring

◦ Exposure (gradual facing)

◦ Symptom management


� Explain role of -ve thoughts on behaviors,

affect & physical reaction

� Negative thoughts may not be 100% valid

and can be modified

� Elicit negative thoughts via patient’s

examples


� What is the evidence for the thought?

� Is there a cognitive error?

� Is there an alternative explanation?

� What is the benefit for that thoughts?


� Use of rational thoughts for substitute the

negative one

� Repeat and say aloud the rational thoughts

� Write down these self-talk statements


1. Set the hierarchy of feared situation with

introduction of Subjective Unit of Distress

2. List the avoidance and safety behaviors

3. Gradual exposure to the feared situation

with experience of habituation

4. Modeling and role play the exposure

5. Imagery or in vivo exposure practiced


� Diaphragmatic breathing: involves taking

smooth, slow, and regular breaths

� How to do it?

1. Take a slow breath in through the nose,

breathing into your lower belly (~ 4 seconds)

2. Hold breath for 1 or 2 seconds

3. Exhale slowly through the mouth (~ 4 seconds)

4. Wait a few seconds before taking another

breath


� http://www.drsammycheng.com/

� https://www.facebook.com/drsammycheng/

� http://apt.rcpsych.org/content/aptrcpsych/8

/3/172.full.pdf

� http://www.ascbt.com/cbt-explained


five-factor (area) model for anxiety disorders: an

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