Intervention L2 - CBT for Anxiety Disorders

Question 1

Briefly, what does the cognitive model tell us about psychopathology?

Answer 1

The situation is neutral, and how react is dependent on our interpretation of the situation.

Question 2

Briefly, what does the behavioural model tell us about psychopathology?

Answer 2

When we behave in a certain way, things reinforce it or punish it.

The environment is either punishing or rewarding!

Question 3

Describe anxiety disorders

Answer 3

• People with anxiety disorders share a PREOCCUPATION with, or persistent AVOIDANCE of, thoughts or situations that provoke fear or anxiety.
• Anxiety is generally associated with anticipation of future problems.
• OUT OF PROPORTION to the situation

Question 4

What is a difference between the thinking styles of people with depression and anxiety?

Answer 4

Depression - rumination of the past (although there is SOME future concerns, it’s mostly rumination)

anxiety - concern, worry about the future.

Question 5

What is panic disorder?

Answer 5

• Recurrent, Sudden, overwhelming experience of intense terror or fright
• Panic is more intense than anxiety; has a sudden onset. Reaches peak within minutes.

DSM-5 - A person must experience at least four of the 13 symptoms in order for the experience to qualify as a full-blown panic attack. Also needs to be followed by maladapative changes in behaviour/persistent worry related to the attacks for one month

examples of symptoms - palpitations, fear of dying, feeling of choking, dizzy, chills or heat sensations, parasthesia

Question 6

Two types of panic attacks?

Answer 6

Cued - expected, or occurring only in the presence of a particular stimulus

Unexpected - appear without warning expectation, as if out of the blue

Question 7

Describe the basic model of a panic attack.

Answer 7

Trigger stimulus > Perceived threat > apprehension > body sensations (e.g. increased HR) > interpretation of sensations as catastrophic!! (e.g. i’m having a heart attack) > leads to more threat > CYCLE REPEATS.

*MISINTERPRETATION of the physiological symptoms leads to MORE anxiety and threat.

Question 8

Describe the Panic Disorder Model.

Answer 8

The panic cycle involves - trigger > physical changes > catastrophic automatic thoughts > anxiety increases > more physical changes….

but over time, anxiety increase also > more exhaustion and anxiety > HYPERVIGILANCE to situations where they could experience an panic attack > OVERSENSITIVITY to small physical changes

this all reinforces the behaviour / disorder.

Question 9

What is a specific phobia?

Answer 9

DSM-5 provides a severity threshold:
• Avoidance or distress associated with the phobia must
interfere significantly with the person’s normal activities, relationships with others; must be persistent.

Question 10

what are some specific phobia subtypes?

Answer 10

Animal Type
• e.g. spiders, snakes, insects, dogs, etc. • Natural

Environment Type
• e.g. storms, thunder, heights, water, etc. • Blood-

Injection Type
• e.g. seeing blood, seeing injury, receiving an injection

Situational Type
• e.g. public transport, tunnels, bridges, elevators

Other Type
• e.g. choking, vomiting, etc.

Question 11

What are some common phobias?

Answer 11

Acrophobia - Fear of heights
Claustrophobia - Fear of enclosed spaces
Zoophobia - Fear of small animals
Hemophobia - Fear of blood

Question 12

Describe social anxiety disorder

Answer 12

• Marked fear of social / performance situations in which the patient is exposed to unfamiliar people, or to scrutiny of others
• Exposure to the feared situation provokes anxiety, which may escalate to panic.
• Anxiety is recognised as excessive or unreasonable by the individual.
• Feared situations are avoided or endured with anxiety w/ a lot of difficulty.
• Reason for avoidance typically fear of negative evaluation, or fear of humiliation of embarrassment/being shamed or exposed

Alcohol abuse often occurs as self-medication, to deal with social situations - it feeds more into the anxiety as they’ll ruminate about what happened the following morning.

Question 13

What is a model for social anxiety disorder?

Answer 13

Event > thoughts > emotion > behaviour

core beliefs: “There is something wrong with me that will be exposed”

eg.

public speaking > “they’ll think im stupid” > anxiety, sweating, fast breathing > avoid public speaking and speak quickly to get event over with.

Question 14

What are some working hypotheses for people with social anxiety disorder?

Answer 14

1. OVERESTIMATION of likelihood of rejection in social situations
2. UNDERESTIMATE ABILITY to cope if a social situation is awkward
3. AVOIDANCE of social situations reinforces maladaptive core
   beliefs and maintains underestimation of coping skills and
   social skills
4. -VE REINFORCEMENT – avoidance of social situations is negatively reinforced as it removes the unpleasant anxiety.

Question 15

What is psychoeducation?

Answer 15

Really just teaching them about their condition. Share with clients an understanding of the problem.

• What is the function of anxiety?
• Giving patients an acceptable alternative explanation to their symptoms, and gives them a sense of CONTROL eg. in panic.
• much of anxiety is about the unknown, psychoeducation FILLS IN THE GAPS - alleviates anxiety and dispels myths.
• Help them understand that avoidance is not helpful and maintains anxiety.
• Go through symptoms of anxiety - helpful so they know their symptoms are normal.

Question 16

What are the main points that should be conveyed in psychoeducation?

Answer 16

• Anxiety is NORMAL reaction to threatening situations/objects
• everybody experiences anxiety to some degree - the disorder itself is common
• anxiety is FUNCTIONAL and DESIRABLE
• it is impossible to ELIMINATE anxiety - just want to be able to function! :) - ref: yerkes-dodson curve

Question 17

What is the Yerkes-Dodson Curve?

Answer 17

It is a curve that shows optimal performance occurs with an ‘aroused’ anxiety level, and that we perform worse in ‘very calm’ and ‘panic’ states.

u-shaped curve.

anxiety facilitates, and debilitates.

so we don’t want NO anxiety :)

Question 18

What is the function of the alarm reaction?

Answer 18

• Help clients see why the symptoms serve a valid and important function!
• Normal symptoms - but they’ve just gotten too extreme.

Eg. increased breathing rate is to increase to supply oxygen to your muscles, readying them to work in fighting the immediate threat, or fleeing from it

eg: increase heart rate to supply more blood carrying oxygen and glucose to your muscles.

Question 19

What is cognitive restructuring.

Answer 19

• techniques to help the person to see the situations that are associated with distressing emotions, in more realistic and helpful ways
• help them to evaluate situations in ways that are more inductive.

Question 20

Three general errors in anxiety disorders?

Answer 20

1. OVERESTIMATING the probability that a -VE OUTCOME will occur.
2. OVERESTIMATING the SEVERITY of the feared negative outcome.
3. UNDERESTIMATING the ABILITY TO COPE or manage in the face of the negative outcome.

Question 21

What are some cognitive targets in Panic Disorder?

Answer 21

• misinterpretations catastrophic cognitions about physiological symptoms
• cognitions about the dangerousness of panic attacks (hence maladaptive behaviour)
• perceptions of poor coping ability/lack of control - help them realise they can cope and survive p attacks
• memory biases for threat related information

Question 22

What are some cognitive targets in specific phobia?

Answer 22

• overestimation of chance or severity of treat eg. the likelihood of being judged.
• memory biases for threat related information
• self-efficacy beliefs about inability to cope.

Question 23

What are some cognitive targets in social phobia?

Answer 23

want to challenge the beliefs …

• fear of negative evaluation - but not everybody needs to like us.
• interpretation of ambiguous audience cues as -ve
• expectation that others are critical evaluators.
• overestimation of manifest anxiety - eg. if i feel anxious in social situations then everyone will notice…but signs of anxiety are not as obvious as they feel.
• realistic performance of self-appraisal
• dichotomous thinking operating rules regarding performance - eg. either performance was show-stopping or it was a failure. there’s lots of in between!

Question 24

What is exposure?

Answer 24

• Gradually asking the client to confront of experience the thing that they fear.
• highlights importance of psychoeducation - They need to understand the reinforcement processes and function of anxiety.
• Importance of therapeutic relationship - Trust the psych, because they know anxiety and have best interest at heart.

Question 25

Examples of exposure?

Answer 25

• imaginal exposure to flying, followed by real flying
• public speaking tasks for social phobics
• exposure to increasingly small and slower lifts, with larger numbers of people

Question 26

How do you create a hierarchy for exposure?

Answer 26

1. Specify a target stimulus - Hierarchy should focus on a single set of stimuli (e.g. even if they’re phobic of a few things, don’t overwhelm, just start with 1).
2. Define the dimensions e.g. for Spiders, Hairy versus non-hairy, moving versus dead, proximity - expose them to what they’re scared of
3. Use the defined dimensions to generate tasks
4. Have the patient give a SUDs (subjective unit of distress) rating for each level and rank the tasks.
5. Negotiate elimination of redundant tasks (e.g. the same SUDs level) and fill in any large gaps in the hierarchy.
6. Develop the final exposure hierarchy, including homework tasks.

there is debate about how far we actually have to go - should we go as far as possible? or will they ever need to reach those extreme situations?

Question 27

What are the steps in exposure?

Answer 27

1. Detailed behavioural interview examining antecedents, responses, phobic stimuli
2. Sharing of RATIONALE with patient
3. Construction of an Exposure Hierarchy
4. For each item on the hierarchy, conduct the exposure tasks (see
   later)
5. Review the exposure session
6. Set appropriate homework
7. Depending on success consider moving along the hierarchy

Question 28

What is a crucial factor in exposure sessions?

Answer 28

The client needs to stay in the situation until their anxiety goes down - if they don’t and exit the situation before anxiety goes down, anxiety will be REINFORCED!!!!!!!!!!

Question 29

What happens if something goes wrong during exposure?

Answer 29

Eg. lift phobic person is in an elevator, and it stops in between floors.

Use that experience as a learning experience. Reinforce the positives, and show them that they can cope.

Question 30

What is imaginal exposure?

Answer 30

when the client imagines the phobic stimulus while relaxed and comfortable - PMR is applied if necessary to maintain relaxation - but aim towards not needing to use it.

• use when in vivo exposure is difficult or expensive
• ideally, it should be combined with in vivo methods.
• imaginal exposure might be difficult for patients to do alone, requires input from the therapist.

Question 31

What is Interoceptive exposure?

Answer 31

Exposure to internal stimuli - exposing them to the physical sensation, so that they habituate to the interoceptive cues, and have a greater sense of ability to cope with the event.

• situations that mimic a panic attack, without them having catastrophic interpretations. Be able to feel it without attributing to panic.
• if someone’s avoiding situations that elicit a symptom - rather than a SPECIFIC situation - eg. increase HR.
• expose them to coffee.

these people will need a very good rationale!!!

Question 32

What are some sample methods of generating interoceptive cues?

Answer 32

• deliberate, forceful hyperventilation for a minute.
• staring at a bright light then a black wall
• shaking head rapidly from side to side.
• placing head between legs for 30 seconds and then standing up quickly.

these all mimic sensations of a panic attack

Question 33

what is homework exposure?

Answer 33

• Integral part of exposure therapy, as they need to continue to have repeated exposure.
• collaborating setting reviewing of homework

repeated exposure enhances treatment response.
frequent exposure to fear stimuli enhances treatment response
generalisation is essential for successful outcome.

Question 34

Why is homework exposure helpful?

Answer 34

repeated exposure enhances treatment response.
frequent exposure to fear stimuli enhances treatment response
generalisation is essential for successful outcome.

Question 35

How do we maintain change?

Answer 35

• Client should never escape or avoid confrontation with the former phobic object
• each potential exposure is an opportunity to consolidate success
• a maintenance plan should be explicitly discussed and agreed to by patient and therapist.