7. Working with People with Anxiety Disorders

Question 1

Since episodic memories are avoided because they are so painful in the case of depression/trauma, why are painful memories in PTSD so easily accessible and triggered?

Answer 1

• people with PTSD have more overgeneralized memories for memories both related and unrelated to trauma. This is due to avoidance of specific painful memories.
• flashbacks are spontaneous and not a deliberate recall of the past. These memories keep coming up precisely because of efforts to avoid thinking about it,

Question 2

Can dominant narratives in people’s lives be self-fulfilling?

Answer 2

Yes definitely. Stories form your identity which orientates your commitments, beliefs, values, goals, aspirations etc.

Question 3

What are the 3 waves of theories for anxiety disorders?

Answer 3

1) First Wave: Behavioral theories
2) Second wave: Cognitive theories
3) Third wave: Acceptance-based (Mindfulness Based Cognitive Theories)

Question 4

What are the 3 aspects of behavioral theories of anxiety?

Answer 4

Proposes that fears are learned through:

1) classical conditioning
2) operant conditioning
3) social learning/ observational learning

Question 5

How does classical conditioning explain anxiety disorders?

Answer 5

Association between previously neutral stimulus and fear after being repeatedly paired with stimuli that induces an anxiety reaction (eg. after having a panic attack outside, you develop a fear of public spaces)

Question 6

How does operant conditioning explain anxiety disorders?

Answer 6

Reinforcement of avoidance/coping behaviors, through repeated pairing of these behaviors and relief of anxiety
Negative experience from being outdoors, you develop avoidant and coping behaviors.
1) Avoidant behaviors - learning that staying away keeps you safe
2) Safety behaviors - learning maladaptive ways of coping which does not help you overcome you fears (eg. using phone in social situation helps you feel safe)

Question 7

How does social learning theory explains anxiety disorders?

Answer 7

Proposes that fears can be acquired through observational learning.
Specific phobias - hatred for cockroaches can be socially mediated. When you see others fearful of cockroaches, you become fearful too.

Question 8

What do behavioral theories of anxiety suggest about intervention?

Answer 8

Suggests that recovery can be achieved by the same learning principles

Question 9

How do cognitive theories explain anxiety? (Hint: Equation)

Answer 9

Proposes that people misinterpret the true level of threat associated with a particular stimuli. Overestimation of threat, and underestimation of coping.
Level of anxiety = perceived probability of threat x perceived awfulness of threat / perceived ability to cope + perceived ability to receive help
*key word: perceived (ie. belief that is shaped by past experiences and learning)

Question 10

What do cognitive theories suggest about recovery and intervention?

Answer 10

Suggests that recovery can be achieved with:

1) insight (formulation)
2) testing of alternative “perception” (intervention)

Question 11

What are the types of anxiety related disorders?

Answer 11

1) specific phobia
2) social anxiety disorder
3) panic disorder
4) agoraphobia
5) generalized anxiety disorder
6) obsessive compulsive disorder
7) post-traumatic stress disorder (PTSD)

Question 12

What is specific phobia?

Answer 12

Excessive anxiety triggered by specific objects or situations (eg. spiders, clowns, water)

Question 13

What is social anxiety disorder?

Answer 13

Excessive fear of being judged negatively by others in social or performance situations.

Question 14

What is panic disorder?

Answer 14

Anxiety about perceived implications of unexpected panic attacks and its consequences (eg. concern that a racing heart means that a heart attack is imminent)

Question 15

What is agoraphobia?

Answer 15

Anxiety about and avoidance of being in places or situations where escape is difficult or embarrassing, or situations where help is unavailable. Fear of panic attacks occuring there.

Question 16

What is generalised anxiety disorder?

Answer 16

Excessive worry about everyday events and problems (eg. work, money, relationships). Physical tension and difficulty relaxing.

Question 17

What is obsessve compulsive disorder (OCD)?

Answer 17

Presence of obsessions or compulsions or both:

1) obsessions - recurrent thoughts, impulses, or images that are intrusive and inappropriate (eg. contamination by germs)
2) compulsions - repetitive behaviors or mental acts to reduce the anxiety related to the obsession (eg. washing hands)

Question 18

What is post-traumatic stress disorder (PTSD)?

Answer 18

• exposure to a traumatic (often life threatening) event where the person’s response involves intense fear, helplessness, or horror.
• re-experiencing symptoms (flashbacks and nightmares)
• avoidance symptoms (trying not to think of what happened)
• hyperarousal symptoms (difficulty sleeping, alert to potential danger)

Question 19

What is a cognitive vulnerability of people with panic disorder?

Answer 19

anxiety sensitivity - concern about the consequences of an attack based on a misinterpretation of physical symptoms

Question 20

What is a cognitive vulnerability of people with social phobia/social anxiety disorder?

Answer 20

Fear of negative evaluation - concern about judgments from others and making a fool of yourself in front of others

Question 21

What is a cognitive vulnerability of people with generalized anxiety disorder?

Answer 21

Intolerance of anxiety - concern about the uncertain future and their ability to cope. Even have metabeliefs about worrying being good or bad.

Question 22

What are some cognitive vulnerabilities of people with OCD?

Answer 22

1) concerned about the consequences of obsessions - “I am going to die from a virus attack if I don’t wash my hands”
2) beliefs about the efficacy of ritual (eg. I must say the prayer 7 times to be safe)
3) intrusive thoughts - take personal responsibility to get rid of that thought and change things

Question 23

What are some cognitive vulnerabilities of people with PTSD? (2)

Answer 23

• negative appraisals post-trauma (“It was really my fault”)
• negative appraisals during flashbacks (“I am going to die”)

Question 24

What are the 2 therapy targets for clients with anxiety?

Answer 24

1) thoughts
- disorder-specific cognitive vulnerabilities
2) behaviors/responses
- avoidance (thought suppression, avoid situations or people)
- safety behaviors (alcohol, self medication, reassurance seeking etc.)
- selective attention

Question 25

According to NICE guidelines, what is the initial treatment options for adults with social anxiety disorder?

Answer 25

Individual cognitive behavioral therapy (CBT)

based on Clark and Wells model or Heimberg model with ‘boxes’ more specific for social phobia.

Question 26

What does the individual CBT comprise of for individuals with social anxiety disorder? (4)

Answer 26

Duration: approx 4 months

1) Psychoeducation about social anxiety
2) Behavioral experiments: to demonstrate the adverse effects of self-focused attention and safety-seeking behaviors.
3) Cognitive intervention: Video feedback to correct distorted negative self-imagery
4) Behavioral experiment: Exposure outside clinic; Systematic training in externally focused attention

Question 27

What are the Aims of individual CBT for anxiety? (3)

Answer 27

• examination and modification of core beliefs
• modification of problematic pre- and post- event processing
• relapse prevention

Question 28

Describe the Formulation Flow for CBT intervention.

Answer 28

Background -> Core beliefs (“Others are successful, settled, and judgmental”) -> Triggering event -> Intermediate beliefs (“I must pretend to be confident so people won’t take advantage of me”) -> Social danger/threat -> Vicious cycle (self-focus/ self as a social object, anxiety symptoms, safety behaviors)

Question 29

How do you teach somebody about anxiety? (Psychoeduation)

Answer 29

Anxiety symptoms are a fight or flight response. These body sensations are your automatic survival mechanism, but you may feel uncomfortable with these sensations when you don’t know why they are happening. (eg. quick breathing, cold hands, butterflies in stomach). Results in hypthervigilance to your surroundings and everything is self-referenced!

Question 30

What are the principles behind psychoeducation? (3)

Answer 30

1) Greater understanding of the function and expression of anxiety in the body. This normalizes the experience and results in less shaming.
2) Greater understanding allows client to not jump to the wrong conclusions’
3) Greater insight can facilitate more top-down executive control of emotions (emotion regulation).

Question 31

Describe the behavioral experiment task to tackle self-focused attention.

Answer 31

Eg. speak to a stranger
Condition 1 - 5 min convo + self-focused attention. Focus on how he was feeling in his body and what was going through his mind during the convo.
Condition 2 - 5 min convo + other focused attention. Focus on what the other person was communicating verbally and nonverbally.
Predicted results - less anxious when asked to focus on others. Help client to change their perceptions that self-focused attention is really not helpful.
If patient is too shy to speak to a stranger, just role play in session first and break down the task into more manageable steps.

Question 32

What are the principles behind the behavioral experiment in tackling self-focused attention? (3)

Answer 32

1) help clients to see the association between self-focus and heightened social anxiety (cognitive result)
2) help client see how this habit could be maintaining his problem all these years
3) skills training in outward-focused attention

Question 33

Describe the cognitive intervention of video feedback for clients with social anxiety.

Answer 33

• Changing self-perceptions (eg. I am an embarrassment).
• Define what it means to be an embarrassment (“keep fidgeting”, “can’t continue convo”)
• speak to receptionist and video record it
• self-rate speaking performance after speaking to the receptionist BEFORE he saw the video.
• 1 week later: watch video and rate ‘the person in the video’ on the same dimensions AFTER he saw the video.
• perception vs objective ratings of himself. Help client realise that perception is different from reality.

Question 34

What is the principle behind the video feedback cognitive intervention?

Answer 34

1) helps to break down and challenge client’s core beliefs using the very criteria that he came up with. Cold hard evidence of a video of himself.

Question 35

What is a limitation of cognitive intervention such as the video feedback intervention? How do you counter the limitation?

Answer 35

Sometimes the client may be convinced rationally, but not feel convinced emotionally. So we need to do more behavioral experiments to reinforce new thoughts of himself.

Question 36

For behavioral experiments outside the clinic, what should the record sheet contain? (5)

Answer 36

1) Target thought or belief to be tested. Rate the strength of your belief in the current thought (0-100)
2) Experiment (eg. face the situation you would otherwise avoid, dropping coping behaviors, behaving in a new way)
3) Prediction
4) Outcome (what actually happened. How does this fit with your prediction? confirm/disconfirm)
5) What does this mean for your original belief/thought? How far do you now believe in it? (0-100) Does your belief need to be modified and how?

Question 37

What is the purpose of behavioral experiments outside the clinical setting? (4)

Answer 37

1) help clients generalise learning in the clinic to other contexts
2) help clients learn that he/she has the ability to cope without safety behaviors
3) help clients learn that his/her self conscious thoughts are not realistic in real life
4) Learning through experience is more powerful

Question 38

Recall what is the 3rd wave of therapies for anxiety?

Answer 38

Acceptance-based theories (eg. Mindfulness-based cognitive therapy MBCT)

Question 39

What does acceptance-based theories such as MBCT emphasize?

Answer 39

• Emphasizes acceptance rather than change oriented therapy (which is emphasized in the first two waves of CBT)
• Learning to look at thoughts as thoughts. Take a step back and observe it. They are not real, they come and go. No point engaging with unhelpful thoughts, so don’t hold on to those thoughts.

Question 40

Why does NICE recommend acceptance based therapies like MBCT?

Answer 40

• positive impacts for both anxiety and depression difficulties
• good to prevent relapse of depression

Question 41

What are the 2 key tenets of MBCT?

Answer 41

1) Being present

2) Separating from thoughts and feelings

Question 42

How do we be present? (2)

Answer 42

• don’t be caught up in past losses or future anxieties

- bring attention and awareness to present body sensations, thoughts, activity, environment etc.

Question 43

How do we separate ourselves from our thoughts and feelings? (3)

Answer 43

• being aware of your thoughts so you can choose not to respond to them in automatic ways
• notice maladaptive thoughts (eg. self-critical thoughts)
• introduce more adaptive thoughts from a distance

Question 44

Mindfulness based therapy suggests that recovery can be achieved by: (3 ways)

Answer 44

1) observing the distress rather than changing it
2) taking clients out of autopilot (automatic ways of behaving/viewing the self or others) by increasing reflection and empathy for the self
3) dampens the fight or flight system and improve emotional regulation

Question 45

What is the content of MBCT sessions?

Answer 45

1) recognise tendency to go into autopilot mode and step out of it
2) notice thoughts
3) use body/breath to ground awareness
4) notice unhelpful responses to thoughts and feelings (eg. fighting it, holding on)
5) learn to accept and allow thoughts and feelings to be there
6) learn that thoughts are not facts
7) self-care
8) planning for future practice
Homework: mindfulness practice

Question 46

When is there a need to use medication for anxiety and depression?

Answer 46

When it is interfering with therapy

Question 47

When should you use MBCT with CBT?

Answer 47

use it in session when client is too upset to do behavior experiments.

Question 48

According to Clarke and Beck’s cognitive behavioral model of anxiety, which aspects are there?

Answer 48

1) cognitions
2) affect
3) physiology
4) behaviors

Question 49

What kind of cognitions do people with anxiety have?

Answer 49

Focus on present or future threat. Highly believable to the person experiencing them, but not accurate representations of the true degree of threat.

Question 50

Why kind of affect do people with anxiety have?

Answer 50

Fearful, apprehensive, stressed, agitated, in response to their thoughts

Question 51

What kind of physiological responses do people with anxiety have?

Answer 51

Fight or flight response

- release of adrenaline leaders to bodily sensations like fast breathing, racing heart, or sweating

Question 52

What kind of behaviors do people with anxiety engage in?

Answer 52

1) avoidance behavior

2) safety behavior

Question 53

What are some environmental factors that can contribute to anxiety?

Answer 53

1) exposure to repeated unpredictable and uncontrollable negative life events
2) growing up in an over-protective, over-controlling family environment
3) specific traumatic events

Question 54

What are some cognitive distortions related to anxiety? (5)

Answer 54

1) jumping to conclusions
- mind reading: assuming people are reacting negatively to you
- fortune telling: arbitrarily predicting that things will turn out badly
2) magnification or minimisation of issue
3) emotional reasoning
- reasoning from how you feel (‘I feel terrified so it must be dangerous’)
4) ‘Should statements’ - self criticism or criticism of others
5) Labelling of the self