Anxiety disorders

Question 1

treatment for anxiety disorders consists of following broad categories

Answer 1

symptom/arousal management skills
exposure based procedures
cognitive skills

Question 2

most prevalent ADs

Answer 2

GAD, social phobia, PTSD (CBT especially effective) , panic disorder

Question 3

psychoeducation content

Answer 3

typical symptoms of anxiety
normalisation of anxiety
alarm response
functional nature of anxiety
educating the client about their specific disorder
educating the client about their specific formulation
education about the range of available treatments

Question 4

anxiety v panic

Answer 4

anxiety:
generally focused on future events
behavioural component of avoidance, caution, agitation, fidgeting
physiological component of muscle tension

panic:
generally focused on immediate danger
behavioural component is escape
physiological component is palpitations and autonomic arousal

Question 5

there is no qualitative difference between normal and pathological anxiety

Answer 5

matter of degree, intensity, frequency, trigger
actual experience of anxiety is same, no different types

Question 6

breathing control training

Answer 6

usually used with panic disorder clients to reduce the impact of hyperventilation

Question 7

hyperventilation happens when

Answer 7

CO2 is expired leading to low conc
low conc is interpreted as high O2 conc
blood vessels constrict, reducing O2 flow

Question 8

breathing control training description

Answer 8

At the very first sign of anxiety or panic, without inhaling, immediately hold your breath and count to 10.
Once you count to 10, slowly exhale, saying the word “Relax” to yourself as you breathe out.
Inhale and exhale through your nose, in a regular six-second cycle
In…2…3…Relax…2…3…
At the end of each minute, again hold your breath for ten seconds, and then repeat Step 3
Continue until the symptoms are under control.

Question 9

Applied relaxation training- PMR

Answer 9

alternate tensing and relaxing of different muscle groups

Question 10

ART rationale

Answer 10

if clients can be trained to recognise the difference between muscle tension and relaxation, they can use increasing tension as a cue to commence arousal management skills

Question 11

ART

Answer 11

occurs in a series of phases over several sessions
long procedure
most steps can be completed in less than one hour, allowing incorporation of other techniques during those sessions
overall process is rationale, begin with slow relaxation of each muscle group, gradually move to increasingly rapid attainment of the relaxation response

Question 12

ART process over sessions

Answer 12

1. rational and awareness
   rationale provided
   client instructed to record time, situation and intensity of anxiety symptoms in diary for HW
2. awareness
   review HW, particular focus given to early anxiety symptoms.
   for HW client records time, situation, type of specific symptom and intensity of anxiety symptoms in diary
3. awareness
   review diary
   for hw client records time, situation, type and intensity, and reaction to anxiety symptoms in diary
4. progressive relaxation (15-20min)
   tension-relaxation process
   Hands, arms, face, neck, shoulders
   hw is to practice relaxation skills twice per day (morning and evening)
5. tension-relaxation process
   Hands, arms, face, neck, shoulders
   Back, chest, stomach, breathing, hips, legs, feet
   hw is to practice twice a day
   6-7. same as above but to release only (without tension first).
   8-9. cue controlled relaxation (2-3mins), release only relaxation, therapist records time taken
   client asked to estimate relaxation time and reinforced for rapid relaxation
   hw is to practice twice a day
6. differential relaxation (60-90sec), use some muscle groups while maintaining relaxation in others.
   in chair, writing at a desk, talking on phone
   hw is to practice twice a day
7. differential relaxation
   standing, walking
   hw is to practice twice a day
   12-13. rapid relaxation (20-30 sec)
   aim to further reduce time required and enhance ability to apply relaxation in natural non stressful situations
   agree on relaxation cue, each time cue occurs, client takes 3 slow breaths, using cue word ‘relax’, scans for tension and focuses on relaxing tense areas
   practice 15-20 times a day in natural situations
   14-16. application training
   brief periods of exposure to stressful situations, with use of relaxation skills in situ
   repeated practice of rapid relaxation in different anxiety provoking situations

Question 13

ART maintenance program

Answer 13

client should scan body at least once per fay and use rapid relaxation to reduce any tension that is present
client should practice differential relaxation, or rapid relaxation at least twice per week
relaxation practice should be built into client routine

Question 14

ART information for client

Answer 14

not hypnosis- you will be aware the whole time
certain physical sensations are normal (tingling, warmth, numbness)
you will not fall forward out of your chair
if you begin to fall asleep or feel uncomfortable, the process can be stopped

Question 15

ATT

Answer 15

blood, injury, injection phobias
trains clients to differentially apply tension to large key muscle groups with aim of preventing blood pressure from dropping and fainting
aims to keep BP up beyond vasovagal response drop

Question 16

ART procedure

Answer 16

Tense the muscles in the arms, chest and legs simultaneously
Continue to apply tension in these muscles until there is a feeling of warmth in the face (usually about 10 – 20 seconds)
Release the tension and relax to starting level. Do not relax too much though.
Wait 20 seconds
Repeat Step 1 to Step 3 a minimum of five times, until the feelings of lightheadedness or faintness have reached a manageable level.

Question 17

Forms of exposure therapy

Answer 17

in vivo exposure
imaginal exposure
worry exposure
exposure with response prevention
interoceptive exposure

Question 18

ABC renewal

Answer 18

different context elicits previous stimulus fear response association
important to build up as many alternative responses as possible and in different contexts

Question 19

Exposure rationale

Answer 19

early rationale based on reciprocal inhibition: pairing of exposure to phobic stimulus with incompatible behaviour
early models of phobia based on simple conditioning processes
increased recognition of inadequacy of simple conditioning models of phobia acquisition
incorporation of cognitive concepts

Question 20

Rachman’s three pathways to phobia

Answer 20

experience it yourself
experience it by association
hear about it (media, verbal transmission)

Question 21

flooding

Answer 21

rapid
direct contact with stimulus

Question 22

exposure mechanisms: classic behavioural therapy

Answer 22

extinction of CS-CR association through repeated exposure to the CS in absence of CR
removal of negative reinforcement for avoidance behaviour

Question 23

exposure mechanisms: foa and kozak

Answer 23

many associations are related to fearful stimulus
when one node is activated, spread in activation across network
some networks are stronger than others, these are repeatedly triggered
you can only change the strength of these activations when the network is activated itself
exposure has maximum effect when: fear networks are activated, within and between session habituation occurs
implied that exposure but be anxiety provoking; repeated; and prolonged

Question 24

exposure mechanisms: bouton’s model

Answer 24

exposure does not operate through unlearning
a new CS-NoCR association is learned
both associations compete for retrieval on presentation of the CS
significant implications for relapse in successfully treated anxiety disorders

Question 25

exposure mechanisms

Answer 25

rachaman et al: exposure works due to increases in patient perception of self efficacy baker et al: no association between foa and kozak key variables and treatment outcome

Question 26

in vivo v imaginal

Answer 26

in vivo more effective generalisation from imaginal to real life may be uncertain some situations may not permit use of in vivo

Question 27

habituation v controlled escape

Answer 27

classical behaviour therapy: habituation necessary for exposure to be effective specific phobia: controlled escape does not impact on exposure efficacy, sense of control gained through controlled escape may be important agoraphobia: exposure to habituation point more effective

Question 28

exposure time duration

Answer 28

procedure must allow enough time for peri exposure decrease in arousal levels continued past habituation point anxiety during exposure generally decreases more rapidly for specific phobias than other ADs

Question 29

flooding v graded exposure

Answer 29

similar effectiveness treatment adherence and drop out rates better with gradual exposure

Question 30

medication during exposure

Answer 30

benzodiazepines reduce anxiety during exposure effect appears to be dose dependent- exposure to feared stimuli as blood diazepam levels peak inhibits extinction of anxiety response benzodiazepines may impair memory consolidation during exposure therapy Beta blockers reduce sympathetic nervous system reactions but do not inhibit subjective fear

Question 31

exposure- realism

Answer 31

more closely exposure tasks mimic real life concerns, more effective immersion in VR

Question 32

exposure- group and individual

Answer 32

group generally effective

Question 33

frequency of exposure

Answer 33

exposure should be between daily - weekly better with longer, more frequent exposure sessions incidental exposure during daily life

Question 34

Craske recommendations for enhancing inhibitory learning during exposure therapy

Answer 34

fewer, longer exposures rather than more, shorter use exposures to challenge specific expectancies that clients have use a range of fear stimuli during exposure wean safety signals and safety behaviours range of different situations/contexts context effects of exposure and renewal effects allow adequate time between exposure trials

Question 35

exposure general technique

Answer 35

Detailed behavioural interview examining antecedents, responses, phobic stimuli Sharing of rationale with patient Construction of an Exposure Hierarchy For each item on the hierarchy, conduct the exposure tasks Review the exposure session Set appropriate homework Depending on success consider moving up the hierarchy

Question 36

how to motivate clients in exposure

Answer 36

highlight discrepancies between ideal and current behaviour rolling with resistance foster self efficacy

Question 37

measuring anxiety/arousal during exposure

Answer 37

SUDs fear thermometer physiological measures (HR, HR variability, vagal tone, startle eye blink reflex potentiation, GSR/SCR) behavioural approach tests

Question 38

BATs

Answer 38

allow therapist to gain realistic measure of avoidance behaviour in realistic setting (often underestimated in self report in safe environment) baseline and outcome access to cognitions otherwise difficult to elicits interoceptive cues as well as external phobic stimuli can be BATs

Question 39

Criticism for BAT

Answer 39

lack validity, narrow in scope time consuming, may not yield information beyond other methods sensitive to therapist instruction method

Question 40

constructing exposure hierarchy

Answer 40

specify target stimulus attributes of it that increase/reduce anxiety operationalise each combination into exposure task SUDS rating for each level, sort task eliminate gaps/redundancies develop final hierarchy, including homework tasks

Question 41

after exposure

Answer 41

discuss typical client reactions to exposure successful/unsuccessful cognitive consolidation - discuss exposure experience - review cognitions before exposure, contrasted with actual outcome - generate future rational cognitions from experience reinforcement: -strong reinforcmenet by therapist for success or attempt -self reinforcement by client

Question 42

dangers/problems of exposure

Answer 42

sensitisation overenthusiasm to progress through hierarchy (excessive demand increases relapse risk) amount of therapist pressure failure to habituate

Question 43

considerations when failure to habituate

Answer 43

are cognitions serving to perpetuate the anxiety? is the patient waiting long enough for habituation should an easier item on the hierarchy be reattempted is the client present not using distraction are safety signals or behaviours being used are medical interventions (benzodiazepines) interfering

Question 44

Ost's single session exposure

Answer 44

The patient makes a commitment to remain in the exposure situation until the anxiety fades away, and never escapes from the situation during treatment The patient is encouraged to approach the phobic stimulus as much as possible, and continue him/herself until the anxiety has decreased or completely disappeared. When the anxiety has reduced, the patient is instruction to approach the phobic stimulus more closely, and stay there until the anxiety has decreased, and so on until the patient is as close as possible. A therapy session is concluded only when the anxiety level has reduced by 50% of its highest value, or completely vanished. less relapse compared with just benzodiazepine medication

Question 45

systematic desensitisation

Answer 45

graduated exposure imaginal exposure to feared sitmuli allows a version of controlled escape, able to return to active relaxation if anxiety of exposure becomes overwhelming

Question 46

Imaginal exposure

Answer 46

when in vivo difficult or expensive ideally combined with in vivo client imagines phobic stimulus while relaxed and comfortable PMR applied to maintain relaxation if necessary

Question 47

maintaining change with exposure

Answer 47

Clients should be encouraged to see each potential exposure as an opportunity to consolidate success Clients must actively engage with the phobic situations or objects A maintenance plan should be explicitly discussed and agreed to by therapist and client

Question 48

flooding used when

Answer 48

time limited clients highly motivated

Question 49

flooding procedure

Answer 49

Form a strong therapeutic alliance Thorough assessment of fears and avoidance Provide education and rationale for procedure Provide prolonged therapist-directed exposure to the most anxiety-provoking situations Therapist describes the situation Therapist models effective performance of the task Therapist instructs client in performance of the task During exposure, therapist should carefully titrate the client’s level of engagement and distress Remain in vivo until there is at least 50% reduction in fear Debrief client’s reactions to exposure as therapy proceeds Repeat until fear is reduced and all avoided situations addressed

Question 50

implosion procedure

Answer 50

In-depth diagnostic interview Formulation-based treatment plan Presenting a treatment rationale Assessment of imagery ability with innocuous stimuli Repeated imaginal exposure to feared stimuli Therapist directed scenes Client as ‘actor’ in the scene Daily homework Flexible treatment session durations (20mins – 3hrs)

Question 51

interoceptive exposure rationale

Answer 51

catastrophic misinterpretation of interoceptive cues reduced self efficacy beliefs about ability to cope

Question 52

interoceptive exposure panic control treatment procedure

Answer 52

Typically a total of around 15 sessions Interoceptive exposure begins in around Session 6, following breathing control, relaxation and basic cognitive skills Interoceptive exposure continues until around Session 10 where exposure is moved to in vivo tasks

Question 53

egodystonic intrusive thoughts

Answer 53

inconsistent with self and moral code

Question 54

exposure with response prevention rationale

Answer 54

If Obsessions cause an elevation in anxiety when they occur… And it is assumed that avoidance of Obsessions means that the person fails to habituate to them… And Compulsions are overt or covert acts that serve to minimise this anxiety… And that the use of such Compulsions is negatively reinforcing because of this removal of the aversive experience of anxiety… Then… Exposure to the feared stimulus should facilitate habituation to it… And allowing anxiety to decrease naturally should prevent the self-reinforcing effect of engaging in overt or covert rituals.

Question 55

ERP component effectiveness

Answer 55

exposure best to address avoidance, rated anxiety on stimulus presentation lower RP best to address obsessive thoughts, urge to perform ritual lower just exposure better than RP, but combined best

Question 56

ERP imaginal exposure

Answer 56

one study found adding imaginal to in vivo ERP improved outcome adding imagery to in vivo techniques may help to limit cognitive avoidance imaginal should not replace in vivo techniques in ERP, but may be considered an optional extra

Question 57

ERP gradual versus flooding

Answer 57

no difference most unwilling to engage in rapid, greater drop out recommended for graduated, speed of progress determined by client readiness

Question 58

ERP duration of exposure

Answer 58

prolonged single exposure sessions rather than more frequnet interrupted habituation within session reductions in peak anxiety across sessions 90 mins usually enough for: anxiety to reduce through habituation; urge to neutralise to abate

Question 59

ERP frequency

Answer 59

depends on client funcitoning, motivation and homework adherence daily for thirty days intensive has excellent results good results also for less frequent sessions

Question 60

Worry exposure rationale

Answer 60

GAD is characterised by recurrent, distressing worries about real life concerns, which are usually subjectively difficult to control Some models of GAD conceptualise worry as a verbal-linguistic phenomenon that serves to allow the client to avoid more distressing visual images of the feared outcome (e.g., Borkovec & Hu, 1990) Worry may therefore, be negatively reinforcing, serving to allow avoidance of visual imagery Habituation to such imagery is also prevented Exposure to these visual images of the feared outcome should allow habituation to such imagery. Once habituation has occurred, the avoidance of worry is no longer required.

Question 61

worry exposure trouble shooting

Answer 61

A convincing rationale must be provided to the client Check for presence of any cognitive errors regarding deliberate evocation of feared imagery If worry exposure elicits only minimal anxiety Is the imagery vivid? Are the images too general? Do they need to be more specific in detail? Have salient images been chosen by the patient / therapist? Is the patient employing coping techniques during exposure? Is the patient self-distracting? If habituation within- or across-sessions does not occur Is the client engaging in covert avoidance techniques during heightened anxiety / exposure? Is the client rapidly moving from image to image without holding each image for long enough to habituate? Is the exposure session terminating too early? Is the time given sufficient for habituation to occur? Be sure to continually monitor subjective anxiety levels during exposure procedures Distraction during worry exposure is seen as counter-therapeutic

Question 62

PTSD gold standard treatment

Answer 62

CBT with breathing, relaxation training, distraction/thought stopping and exposure strategies

Question 63

DTE direct therapeutic exposure

Answer 63

direct exposure to event memories usually 9-14 sessions, 1-2 per week, 60-90 mins significant other as 'ally' audio recording in session, playback for homework incorporates writing tasks for homework safe, collaborative, empathic relationship

Question 64

DTE overall program

Answer 64

Sessions 1 – 2 The patient is asked to describe the incident(s) The level of detail that is tolerable is left up to the patient The initial description can be purely verbal but should move to an imaginal exposure format as soon as possible Sessions 3 – The patient continues to recount the event(s) in the present tense, in an imaginal exposure format The therapist encourages increasingly rich, detailed recounting of the event(s) through questioning.

Question 65

Full cognitive therapy

Answer 65

based on systematic evaluation of cognitions: realistic? helpful? consistent?

Question 66

CT in anxiety- realistic concerns

Answer 66

may be more useful to initially examine what the patient thinks may happen if they were able to change their beliefs focus on the goal outcome and the utility of the belief

Question 67

three general cognitive errors

Answer 67

overestimating the probability that a negative outcome will occur overestimating the severity of the feared negative outcome underestimating the ability to cope or manage in the face of the negative outcome

Question 68

Socratic questions

Answer 68

questions for clarification probe assumptions reasons and evidence viewpoints and perspectives implications and consequences questions about the question