Cognitive Behavioural Therapy of Anxiety Disorders

MRCPsych Course 2011

Sally Standart

Anxiety Disorders (ICD-10)

• Phobias – agoraphobia, social, specific • Panic Disorder• Generalised Anxiety Disorder GAD• Obsessive Compulsive disorder OCD• Post-Traumatic Stress Disorder PTSD• Adjustment Disorders• Conversion Disorders• Somatoform Disorders

General principles

• People experience anxiety when they think situations are more dangerous than they really are

• Goals of treatment are to help person consider alternative, less frightening explanations

• Needs to be individualised, based on jointly derived alternative explanation (i.e. formulation)

Safety behaviours

• Behaviours which the patient engages in to try to avoid a feared outcome

• Safety Behaviours: – Increase self-consciousness/self-focus– Can increase feared symptoms (sweating, s etc– May draw unwanted attention to self– May contaminate the social situation – Increase the belief that they are effective– Prevent disconfirmation of this belief

Social Phobia (Clark & Wells)

Social Situation

Processing of self as social object

Activates assumptions

Perceived social danger

Safety BehavioursSomatic & cognitive

symptoms

Social Phobia: step by step (Clark)

1. Develop personalised model2. Experiential learning exercise3. Live feedback using audio/video4. Attention training exercises5. Interrogate the social environment using behavioural experiments6. Deal with anticipatory anxiety & post mortem7. Re-script early memories associated with mental imagery8. Construct a more realistic social self-image9. Tackle remaining assumptions

Model of OCD(Wells & Matthews, 1994)

Trigger

Activates meta-beliefs

Appraisal of intrusion

Beliefs about rituals

EmotionBehavioural response

OCD: step by step (Salkovskis)

• Engage in assessment – make patient feel understood• Reach shared understanding of problems through formulation• Discuss alternative explanations• Engage in treatment – help patient choose to change• Help patient actively test alternative hypothesis and explore

implications• Generalise change• Relapse prevention

Meta-beliefs Thoughts about the nature of intrusions

• Thought-Action Fusion (TAF)– Thoughts are as bad as actions– Thoughts of an event mean I have probably done it– If I think something, then I will do it

• Thoughts can cause events (Thought-Event Fusion)• Attentional strategy consequences

Beliefs about Rituals

• Positive beliefs concerning neutralisation– Checking is the only way to feel better– If I don’t stop this feeling, I’ll go mad– If I complete _____ without thinking _____, everything will be OK

• Negative beliefs concerning neutralisation– I have no control over ______– Rituals can damage my body

Targets for Treatment

1. Meta-beliefs– Via appraisal of intrusion– Is this my OCD or an important thought?– e.g. sparrows on the way to work…..

2. Beliefs about rituals3. Behavioural responses

– As a route to challenging 1 & 2.

Normalising

• Unacceptable intrusions are a normal occurrence (Rachman & Da Silva work in 1970s)– Problem lies in interpretation or appraisal of them

• Useful to worry about some things to some extent– Problem lies in belief that harm may arise if worries not

controlled or counteracted in some way• Some precautionary measures can be useful in some situations

– Problem arises when person tries too hard (to get rid of thought, prevent harm, become certain, be clean etc) so……THE SOLUTION BECOMES THE PROBLEM…….

Behavioural Experiments

• How can we test the validity of this belief?

• If you changed (behaviour), what would be the outcome if (belief) was true?

• Describe in detail (time course, severity) the predicted outcome

Behavioural experiment record sheetSituation Prediction Experiment Outcome What I

learnedDescribe situation in detail

What exactly did you think would happen?

How would you know?

Rate belief

What did you do to test the prediction?

What actually happened? Was your prediction correct?

Balanced view

Re-rate belief

How likely is what you predicted to happen in the future?

Exposure & Response PreventionERP• Define belief to be tested• Decide on exposure - ? graded hierarchy

– May need to go beyond non-obsessional to anti-obsessional– Therapist modelling in early experiments– Maintain balance of responsibility with patient

• Identify typical/likely response to feared stimulus• Rate anxiety/discomfort/fear before, during and after exposure• Record outcome• Repeat & review

Overcoming Resistance

• Pros and cons of existing behaviour vs new behaviour

• Guarantees……..• Goal setting to aid motivation• Involve significant others• Be aware of your own behaviour as a therapist –

are you inadvertently facilitating the patient’s avoidance?

Relapse Prevention

• ‘Discharge’ = final big experiment• ‘Setback’ vs relapse• Utilise setbacks in course of therapy for learning• Discuss the future and anticipate problems• Keep long term goals in focus• Therapy ‘blueprint’ and action plan• Consider holding back one appointment for review after longer

period

Resources/References

• Cognitive Therapy of Anxiety Disorders: A practice manual and conceptual guide. Adrian Wells

• Overcoming Anxiety. Chris Williams