Week 6 - Anxiety Disorders Flashcards
The Anxiety Disorders DSM5
- Separation Anxiety Disorder
- Specific Phobia
- Social Anxiety Disorder
- Panic Disorder
- Agoraphobia
- Generalized Anxiety Disorder
Selective Mutism
Substance / Medication-Induced Anxiety Disorder
Anxiety Disorder Due to Another Medical Condition
Other Specified Anxiety Disorder
Unspecified Anxiety Disorder
Psychoeducation
Why?
Knowledge really is power!
To normalise
To educate and inform
Our job is to help the client to help themselves – and they require knowledge to do that
To dispel myths
Psychoeducation
What and When???
Right at the beginning
Prevalence rates – to normalise
Different types of anxiety – that people worry about different things
Anxiety is a normal and even ADAPTIVE
Becomes problematic when it stops people doing what they WANT to do or what they HAVE to do
Four aspects of anxiety (thoughts, feelings, behaviours, physiology)
Potential CAUSES of anxiety (trauma, learning, genetics, avoidance, reassurance seeking) – just generally at this stage
More specific information on their particular disorder
Explanation that in children and teens: it can come across as anger and frustration
What and When???
conceptualisation, children/parents, strategies
Quite early in the peace
- –Sharing of conceptualisation – here you can give more detailed information on what may have caused, and is maintaining, THEIR particular anxiety issues
- –When the preschooler / child / teenager is the client – parental information outlining all of the above PLUS information on parenting traps (e.g., allowing avoidance, providing reassurance, over-protection / over-control etc.)
When introducing particular strategies
- -Rationale behind particular strategies
- -Education on the fear response – when talking about the recognition of body signs and introducing relaxation
- -Education on the ABC model when introducing cognitive strategies
- -Education on the role of avoidance in maintaining anxiety when introducing graded and / or interoceptive exposure
Psychoed
how
As a general rule: don’t just tell them! There is a LOT of information and they will NOT remember it all
Handouts that you can go through together is useful – provide the information and then discuss how each piece of information may / may not apply to their situation
Make sure it is age appropriate!!!
Sharing of the conceptualisation:
Why?
To come to a shared understanding of what is maintaining the client’s anxiety
Work WITH them to come up with the conceptualisation rather than just present it to them; using a current anxiety example is useful
Understanding of WHAT is going on and WHY the anxiety is being maintained provides the rationale for the treatment plan
Should be based on the theoretical models, but tailored for the individual client – and when you present it, don’t use psychobabble!
Diagrams are often useful
Need to present it in an age appropriate manner
Kids – just very basic – let them draw it and colour in boxes etc.
Teens – can be more ‘adult-like’
Relaxation
Psychoeducation Recognition of anxious body signs Mindfulness Abdominal breathing PMR
Psychoeduction: The Fear Response (teens and adults only)
- Evolutionary and biological
- When there is danger our ‘Flight or Fight’ response is initiated – that is, our body prepares us to either fight (the threat) or flee from it (get away)
- Our autonomic nervous system is activated – adrenaline and noradrenaline are released
- Why? When there is a real threat, the big muscles in our arms and legs need significant blood and oxygen to fight or flee
- To get oxygen to the major limbs quickly, respiration increases so that the heart can pump faster and get oxygen there as fast as possible
- But this means that other body parts such as the skin, hands, feet and gastrointestinal system, do NOT get as much blood and oxygen as those systems are not as necessary for survival under threat. So people may get cold, tingly, numbness, digestive problems
- With increased oxygen comes increased heat – so sweating can occur
- Pupils dilate to let in as much light as possible so that we can see more (to detect threats etc) – can get visual issues
Problem: we’re not usually fighting a lion…we’re about to sit an exam, talk to somebody we don’t know, worry about an upcoming interview! So we have TOO MUCH oxygen then – lightheaded, dizzy, feeling unreal, blurred vision
Body Signs as a Rationale
Rationale:
- How we know when we’re feeling anxious
- Early detection means you can do something about it before it intensifies
- Need to first work out what our anxious body signs are
Body Signs: Children
examples:
Frank N. Stein
Body sketch – butcher paper outline for each child – mark and draw body signs
Body Signs: Teens
Get them to complete a checklist of body signs – similar to adults
example:
My Anxious Body Signs
blushing heart racing dry mouth lump in throat butterflies in stomach feeling sick / nausea diarrhoea shaking tingling / pins and needles goosebumps trembling knees feeling dizzy / faint difficulty breathing sweaty palms
Relaxation Psychoeducation (rationale and types)
Rationale
- -Anxiety leads to body signs
- -We can use relaxation exercises to calm down those body signs
Many different types – these are just a selection
- Deep breathing – to counteract the hyperventilation caused by rapid shallow breathing – helps to calm down the other body signs as a result
- Progressive muscle – muscles tense ready for flight or fight
- Guided imagery – takes us away from our worries and concentrate on something pleasant
- Mindfulness exercises – stops the mind whirring – anxiety is often future-oriented – mindfulness brings us back to the present
Tips for effective relaxation Practice! -Make a convenient time -Find a quiet and comfortable place -Keep a record of your practice
Relaxation Strategies
Abdominal Breathing
We breathe in O2 and breathe out CO2
Need to maintain a balance for the body to work efficiently
Balance is maintained by the rate and depth of our breathing
- –When we exercise – increase in O2 and CO2 and so the balance is maintained
- –When we relax – decrease in O2 and CO2 and so the balance is maintained
- –When we’re anxious we over-breathe / hyperventilate – balance tips over so we have too much O2
Leads to other body signs – dizziness, light-headedness, confusion breathlessness, blurred vision, numbness, tingling in the extremities, cold clammy hands, muscle stiffness, feeling hot, flushed and sweaty, excessive sighing and yawning
Can leave the individual feeling exhausted and tired
Abdominal Breathing
step 1
Step 1: Chest or stomach breathers?
Place one hand on belly and one on breastbone when breathe – which hand moves more?
Practice so that the hand on their belly moves more than the hand on their chest
Abdominal Breathing
Step 2: Establish breathing pattern
Relax shoulders, chest and jaw
Breathe in slowly through the nose by relaxing and expanding the tummy (hand on tummy should move!)
Do not take deep breaths – just your own depth of breath that is smooth and easy
Breathe out through the mouth, letting the air ‘fall out’ naturally
Placing a book on the stomach can help you keep your breathing slow and low
Abdominal Breathing
Step 3: Breathing Timing
Everyone is a bit different…
Generally: In for 4, hold for 2, out for 6 seconds
It that’s too hard: in for 3, out for 4 seconds and work up to 4-2-6
Can add the word ‘hundred’ after each counted number to regulate
EVENNESS of breathing is the most important
(apps, breathe 2 relax, belly biofeedback, breathing lessons, etc)
Mindfulness
Comes from Buddhist meditation practices
Being in the present moment
Being aware of what is happening both within and outside of you, moment by moment and without judgment
Use all five senses to remain and / or return to the present moment
Important to remember that the mind WILL wander – but to notice that without judgment and return to the present
Anxiety – future focused – often not living in the present, but worrying about something that may or may not happen in the future
Mindfulness exercises can help to ground those suffering with anxiety
There are all sorts of different mindfulness-based exercises
Formal – e.g., with scripts, sitting in a particular position etc
Informal – e.g., being mindful while doing mundane tasks
Progressive Muscle Relaxation (PMR)
`When we are anxious, our muscles tense, getting us ready to fight or flee
But again…there is no lion! There is nothing physical to fight or flee from and so our muscles can remain tight and lead to aches, pains and tension headaches
PMR teaches clients the difference between the tense state and the relaxed state
Not only is it progressive in terms of the different body parts one turns their attention to, but we can also teach it ‘progressively’ as well
Many different versions of this…
Cognitive Work
various techniques
Many more cognitive techniques than there are cognitive theories! The usual suspects:
- Explanation of the ABCD model
- Identification of negative automatic thoughts – dysfunctional thoughts record
- Identification of cognitive distortions
- Identification of underlying core beliefs – downward arrow technique
- Cognitive challenging techniques
- Replacing unhelpful thoughts with helpful ones
- Coping self-statements
- Problem solving
In fact…whenever you are working with thoughts in whatever way…you are doing cognitive therapy…that includes ‘accepting’ the thoughts
potential cognitive treatment./techniques (the way we like to do it)
Some steps – not exhaustive – just some ideas:
- -Explain the cognitive model
- -Ensure they understand the cognitive model
- -Teach them about different thinking styles
- -Teach them about coping statements
- -Teach them about cognitive restructuring
Ways to help teach:
- -Explain the material
- -Get them to practice with non-personal examples
- -Get them to practice with personal examples
Explanation of the ABCD Model
Antecedents: Event/Situation
Beliefs: Thoughts
Consequences: Emotions
Do: Behaviour
When an event (A) happens, it is our thoughts and interpretations of the event (B), & not the event itself that leads us to experience certain emotions (C), and act in particular ways (D)
The Thought-Feeling Connection
Need to get across to the client that situations do not lead to our emotions, but rather, our thoughts lead to our emotions
Children as young as 7 years can do this!
It’s very important that they understand this
Use stories (for adults too!) to help them understand the connection
Use exercises to ensure and cement that understanding
What are thoughts?
Thoughts are what you say to yourself in your head
Different thoughts lead to different types of feelings
Sometimes thoughts can be pictures in your mind, rather than words.
It can sometimes be difficult to notice thoughts because they seem automatic
You can control your thoughts and choose to think in helpful ways
(It may sound strange, but not all teenagers know what you mean when you talk about ‘thoughts’.
This section aims to educate teenager on the characteristics of thoughts)
Connecting thoughts and feelings examples
match the thoughts with the feelings:(for children)
eg. “I have no one to play with” > Lonely
Thought Bubbles (for children):
- event: kates mum is late to pick her up from school
- thought: “mum has forgotten about me”
- how would kate feel? - shitty
- what would kate do? - cry
Feelings Detector: Teens
eg. nick has started at a new school, thought: “I have no one to sit with at lunch”, feeling: ….
Mind Reader: teens
eg. Meg is about to do a school exam, she feels really nervous what might meg be thinking? “fuck i wish they told us what was actually going to be assessed”
Activating helpful thoughts:
unhelpful thought, leads to feeling nervous leads to making excuses to not going on date: VS making a helpful thought, leading to less nervousness, goes on date.
Overall – trying to get across the idea that…
Anxious thoughts => Anxious Feelings
Helpful thoughts => Calmer feelings
Common Cognitive Distortions
All or none thinking (dichotomizing / perfectionism / polarised thinking) – e.g., if I don’t get 100% on my exam, I have failed
Overgeneralisation – generalising from one event to ‘all’ events
Catastrophising – can be present or future oriented (i.e., seeing things as worse than they really are or expecting things to go very wrong in the future)
Filtering – filter out the positives and magnify the negatives
Disqualifying positives – turning neutral or positive things into negative ones
Personalisaton – taking everything as a reaction to the self – blame yourself for everything
Jumping to conclusions (mind reading) – thinking we KNOW how people feel and think without actually asking
Attribution errors– believing we know a person’s intention for their behaviour e.g., they ‘meant’ to do that!
Emotional reasoning – feelings are reality
“Shoulding” – should, shouldn’t, oughts, musts
Labeling of self and others
A reminder of the steps
helpful/unhelpfulthoughts, ABCD model
There are numerous versions
Use a thoughts record
Step 1: Identify the situation
Step 2: Identify and rate the mood
Step 3: Identify the unhelpful thoughts (and cognitive distortions)
Step 4: Identify evidence that supports the unhelpful thoughts
Step 5: Identify evidence that does not support the unhelpful thoughts (questions!)
Step 6: Identify and rate a more balanced thought
Step 7: Re-rate the mood
Step 1: Identify the situation
Who?
What?
When?
Where?
Step 2: Identify and Rate Mood
What did you feel?
Rate each mood (0-100)
Step 3: Identify Unhelpful Thoughts
What was going through your mind just before you started to feel this way? Any other thoughts? Images?
Circle the ‘hot’ thoughts
Step 4: Identify evidence that supports the ‘hot’ thought
It is important not to discount / invalidate evidence that supports the clients unhelpful / hot thoughts
Step 5: Identify evidence that does not support the hot thought
Have I had any experiences that show that this thought is not completely true all the time?
If my best friend or someone I loved had this thought, what would I tell them?
If my best friend or someone who loves me knew I was thinking this thought, what would they say to me?
What evidence would they point out to me that would suggest that my thoughts were not 100% true?
When I am not feeling this way, do I think about this type of situation any differently?
How?
When I have felt this way in the past, what did I think about that helped me feel better?
Step 5: Continued
Have I been in this type of situation before? What happened? Is there anything different between this situation and previous ones? What have I learned from prior experiences that could help me now?
Are there any small things that contradict my thoughts that I might be discounting as not important?
Five years from now, if I look back at this situation, will I look at it any differently? Will I focus on any different part of my experience?
Are there any strengths or positives in me or the situation that I am ignoring?
Am I jumping to any conclusions in terms of my unhelpful thoughts (or evidence supporting my unhelpful thoughts) that are not completely justified by the evidence?
Am I blaming myself for something over which I do not have complete control?
Coping Statements: Helpful Thoughts they Prepared Earlier!
A ‘mantra’ about how to cope in a difficult situation
Can be prepared beforehand and practiced out loud
Can even be put on cards to be kept in a wallet or on the fridge!
Coping Statements: Teaching
Can use a teaching task first before developing there own.
eg. Unhelpful thought “I can’t cope!” > coping statement: “Everyone makes mistakes, no one is perfect.”
Additional Cognitive Strategies for GAD
-Quick Recap: (WELLS’)Model of GAD
Positive beliefs about worry – worrying helps me cope, worrying helps me to solve problems, worrying makes me prepared
Type 1 worries – worry about external events e.g., welfare of child
Negative belies about worry – that worry is harmful
Type 2 worries - worry – e.g., my worry is uncontrollable, worrying is harmful, I could go crazy with worry
Behaviour – avoidance (social events, unpleasant news items, agoraphobia) not just of external events but also to prevent worry; reassurance seeking
Thought control – thought suppression, use worry to avoid processing strong emotions, distraction – they are ultimately safety behaviours
Emotion – feelings and physiological responses
Quick Recap: Model of GAD 2
DUGAS
Very similar to that of Wells – 2 additions
- -Intolerance of uncertainty drives everything
- -Negative problem orientation – belief that that problems are too hard, unsolvable. Not problem solving ability per se – approach to problems
Also explicitly looks at the effects of mood state and life events and their impact
important points (how to explain, etc.)
You need to explain these cognitive models and their components to the client in terms they will understand
You need to explain how THEIR experience fits in to these models and come up with their own tailored model collaboratively
GAD people are ALREADY over-engaging with the cognitions – what they don’t need is to be in their head even more!
Best not to try to cognitively challenge Type 1 worries – they already have worked out every possible contingency and you won’t win!
Best to cognitively challenge Type 2 worries – worry about worry, negative beliefs about worry, and positive beliefs about worry
A bit of extra psychoeducation…
worry, suppression and what if
Sell the idea of worry about worry and focusing on that. The client will understand that working through one external worry topic will just lead to it being replaced by another – so better to work on the mechanism. If everybody worries, then why is only problematic for some? Because they worry about that worry. If they could think “there’s another worry and who cares?”, how much of a problem would their worry be?
Suppression experiment – white bear / pink elephant – to show that cognitive avoidance isn’t really working for them
The ‘what if’ experiment – go through and keep saying ‘what if….worst case scenario’ – demonstration that worry is NOT a useful problem solving or coping strategy – leads to more rumination and more catastrophic ideas
Cognitively Challenging Type 2 Worry and Negative Beliefs about Worry
- Evidence for and against negative beliefs
- Question the mechanism – e.g., How would worry make you go crazy? What’s the evidence for that? Also bring out the evolutionary card!
- Question the uncontrollability of worry – e.g., distraction can stop worry – if worry was uncontrollable, distraction would make no difference
- Normalising worry – give them the stats (79% worry over a 2-week period) – so it is normal, not weird etc. Could also set a behavioural experiment to test that out – survey people to see how many of them have worried in the last 2 weeks.
Cognitively Challenging Type 2 Worry and Negative Beliefs about Worry
Dissonance Techniques – alert the client to the fact that they have both positive and negative beliefs about worry. They believe worry is both harmful and helpful. How does that work? Some will point out that TOO much worrying might be harmful. You can counter that with, “then more worrying would also be even more helpful.(is this meant to say harmful?)”
Can do a behavioural experiment as well – let them worry like crazy and see if it harms them in any way.
Behavioural Experiments for Negative Beliefs about Worry
Setting worry periods - challenging uncontrollability beliefs. Set 15 minutes a day to worry and only worry if you need to when you get to the specified time. Demonstrates they CAN control their worry
Loss of control experiments – ask the client to push their worry to the limit and see if they lose their mind / go crazy / do stupid things etc – during worry periods or in situ
Banning thought control procedures
Surveys – e.g., ask friend / colleagues whether they worry etc.
Cognitively Challenging Positive Beliefs about Worry
Can use the ‘usual’ strategies
Retrospective mismatch – ask the client to describe in detail their last anticipatory worry and exactly what they expected to happen. Then ask them to describe what ACTUALLY happened.
Prospective mismatch – ask the client to provide you with detail concerning an upcoming event they are worried about. For homework they enter the situation and contrast what they WORRIED would happen versus what ACTUALLY happened
Trying to demonstrate that worry is not an accurate representation and therefore not as useful as they might have thought
Cognitively Challenging Positive Beliefs about Worry
Banning worry – if worry prevents them from being surprised, getting into trouble etc., then see if they get surprised or get into trouble if they abandon their worry
Worry more! Can use this both for challenging and negative AND positive beliefs about worry. Ask them to worry as much as they can and see whether it does in fact increase performance, prepare them more etc
Challenging Cognitive Biases
GAD clients tend to scan for evidence confirming their beliefs about Type 1 worries e.g., search paper for health issues / violence etc.
- -Why not assess and search once and come up with a plan (question the frequency)
- –Ask them to scan the REAL world for evidence of REDUCED risk
Other useful strategies…
GAD clients tend to look only at catastrophic endings and see them as more likely than they really are
—Encourage them to come up with neutral or positive endings and to at least give them equal probability of occurring
Letting go of worries – yes this is in Wells’ book – not as ‘new’ as everybody thinks!
—“Here’s another worry – it doesn’t mean anything – let it go” or “I’m worrying – it doesn’t help me – let it go”
Exposure to Type 1 and Type 2 worry – more about that later though…
Dealing with Intolerance of Uncertainty (IU)
In the Dugas and colleagues model – IU is the main driver of worry
Those with GAD have an ‘allergy’ to uncertainty – even small amounts can be problematic!
Can’t reduce uncertainty and so we have to increase tolerance to uncertainty
Use behavioural experiments to seek out uncertainty e.g., send the low-importance email without proof reading it
Give them a list of ‘typical’ examples of IU
Dealing with IU
types of behaviours
- avoiding doing certain things because the “outcome” is uncertain
- Finding imaginary obstacles for not doing certain things
- Procrastinating
- Not delegating tasks to others because of uncertainty that others will not do it “right”
- Only partially committing to a task, a project or a relationship
- Seeking a great deal of information (reading, asking advice) before making a decision
- Questioning a decision because of uncertainty about whether it is the “right” or “perfect” decision
- looking for reassurance from others
- reassuring oneself with exaggerated optimism
- double-checking or redoing things several times to be certain that they are correct
- over-protecting others, doing things for them.
Dealing with Negative Problem Orientation (NPO)
It is NOT problem solving ability per se, but rather their attitudes towards problem solving
Doubt their PS ability
See problems as threatening
Pessimistic about problem solving outcomes
All due to IU – as outcomes are uncertain
Feel frustrated and anxious in the face of problems
Increases ‘what ifs’ as problems remain unsolved and worry leads to further problems!
Problem Solving – Step 1
Help the client discriminate between the problem itself and their emotions about it – oftentimes they see their emotions AS the problem
The negative emotions are ‘cues’ – and to write a list of problems when they occur
Problems are normal
Distinguish between viewing problems as ‘threats’ as opposed to ‘opportunities’ – and that this distinction is a continuum not a dichotomy!
Their challenge is to find the opportunity
Problem Solving – Step 2
Problem solving training:
What is the problem?
What is the goal?
What are the alternative solutions (pros and cons)
Pick one
How well did it work?
POINT OUT HOW THIS IS DIFFERENT TO WORRY!!!!!!!!
Exposure - rationale
Need to explain first how anxiety works – i.e., the anxiety cycle
THEN you need to emphasize the role of avoidance in the maintenance of anxiety
THEN you need to explain that the ‘remedy’ for avoidance is exposure
Avoidance: cycle of negative reinforcement
example
see a dog > unhelpful thoughts > anxiety!! > AVOID!! > Feel less anxious initially > do not lear that you can cope. Do not learn that the negative consequences you are worried about are unlikely to happen!~
Rationale for Exposure
to get over it, we have to go through it
Build on effects of avoidance to discuss rationale for graded exposure
Exposure is the “answer” to avoidance
Link back to ‘breaking’ the anxiety cycle (diagram)
Exposure therapy
Facing the fear – exposure
Based on principle of
habituation to fear
With Response Prevention – E/RP
—-Resisting escape, safety seeking, neutralising behaviours
In vivo or imaginary
Gradual or flooding, intensive or slow
Evidence for GRADED exposure
Exposure to external stimuli or internal cues
- —-Interoceptive exposure – PANIC DISORDER
- —-Obsessions / intrusions - OCD
- —-Phobias, panic, agoraphobia, OCD and PTSD
Constructing an exposure hierarchy
Work out a goal
Think of as many steps as possible
Put them in order – using your fear thermometer (SUDs)
Check for gaps (no more than 2 points)
Write down a BRAVE Step Ladder, and negotiate rewards for each step
- Work out a goal
Work out a goal
What fear would the person like to overcome?
What is the ultimate goal the person would like to achieve?
Ensure the goal is specific, realistic, & central to their primary diagnosis
- Think of as many small steps as you can
Based on client monitoring of symptoms and rating severity of symptoms using Subjective Units of Distress (SUDs)
Give client small pieces of paper
Choose the fear they most want to work on
3 situations related to the fear that the client finds a little worrying, 3 situations they worry a lot about, and 3 situations they find extremely worrying (as a start!)
Ask the client to give a fear rating of each situation
- Place the steps in ..
order of difficulty
- Check for gaps between the steps
No steps should be more than 2 points apart
- Write down your ladder and negotiate rewards (for kids)
-Write down the ladder
- Rewards (for kids / teens)
- –Do you know what rewards are?
- –Why do you think you get rewards for completing each step on the ladder?
- –When do you think you should get your reward?
- –Emphasise that they must NEGOTIATE rewards with their parent(s)
- –Explain the ‘practise’ and ‘completed step’ rewards
Beers?
YES!
