Cognitive Behavioral Therapy for Anxiety – an introduction

1. Cognitive Behavioral Therapy for Anxiety – an introduction PREP Prevention and Recovery of Early Psychosis Kate Hardy, Clin.Psych.D Post Doctoral Fellow Prodromal Assessment, Research and Treatment Team (PART), UCSF Kate.Hardy@ucsf.edu

2. Objectives • Develop a shared formulation of anxiety with a client • Elicit negative automatic thoughts with a client • Use the downward arrow technique to explore core beliefs • Apply cognitive and behavioral interventions in the treatment of anxiety • Know where to locate further reading and information regarding CBT for anxiety

3. What is Anxiety? • Anxiety disorders are • common • chronic • the cause of considerable distress and disability • often unrecognized and untreated • Anxiety disorder is umbrella term includes disorders such as social phobia, OCD, PTSD, Panic Disorder • Each has different symptoms but all cluster around excessive, irrational fear and dread • Co-occurrence with other disorders

4. Generalized Anxiety Disorder • Excessive and hard to control persistent worry • Associated with physical symptoms, difficulty concentrating, irritability • Not confined to features of other disorders i.e. anxiety is not about having a panic attack (Panic Disorder) being embarrassed in public (Social Phobia) or being contaminated (OCD)

5. Treatment Guidelines • Guidelines recommend use of psychotherapy (CBT) in treatment of anxiety disorders • NIMH – Medication will not cure anxiety disorders but will keep them under control while the individual receives psychotherapy

6. Core beliefs Underlying assumption Critical incident Activate assumptions Thoughts Feelings Behaviour Physical Cognitive Model Early Experiences

7. Early experiences lead people to develop core beliefs • From core beliefs unhelpful assumptions are generated that organize perception and govern behavior • Critical incident triggers the assumptions • Leading to negative automatic thoughts (NAT’S) which have knock on effect to mood, behavior and physiology

8. Five Areas Model Environment Thoughts Biology behavior Mood

9. Formulation of safety behavior EVENT James rearranges plans Consequence (Potentially) perceived by James as annoying and needy . James gets frustrated, Sue worries further and seeks more reassurance Action Reassurance seeking ‘Do you love me?’ THOUGHT He does not love me Feeling Upset and anxious

10. Exploring what barriers to engagement and ways around these barriers • Look at secondary gains and identify these • Explore expectations of therapy • Validation of experience • Motivational interviewing

11. Miracle Question/Scaling • If I had a magic wand (if a miracle happened overnight) and I could use that wand to change everything for you over night so that everything was better for you what would be the first thing that you would notice in the morning that would tell you things had changed?

12. Negative Automatic Thoughts • Aim is to encourage the client to notice what is going through their mind when they have a strong reaction to a situation • Link this thought to an emotion and rate the emotion • Thought is an interpretation of the situation and it is this thought that governs the emotional response • The thought with the highest emotional rating is the hot thought (NAT) • Practice in pairs using Russell’s case example

13. Downward Arrow • Technique to identify underlying assumptions and core beliefs that drive the NAT’s • Explore what the NAT means to the individual (if that were true what would that mean?) • Can also ask the client to complete the following statements: • I am • Others are • The world is

14. Case Study – Christine • Referred to psychology for neuropsychological testing regarding memory difficulties • Very anxious when arrived and during testing • Fearful that she was experiencing dementia

15. Background • 60 year old woman, housewife • Husband recently made redundant • Lived with husband and youngest son (24) • Noticed increasing memory problems over the last few months • Interview with husband revealed this was situation specific

16. During testing was very anxious which impaired performance • Conclusion from testing was MCI (age related) with anxiety as contributing factor • Had to be careful re Christine not feeling validated

17. In feedback session was offered sessions around anxiety management • Amenable to this but doubtful it would be helpful • Also adamant didn’t want to explore past issues • Contracted for twelve sessions of CBT

18. Formulation I’ll make a fool of myself I won’t remember what to say New Situation Avoid new people Avoid new situations Worrying Ruminating Heart racing Impaired ability to concentrate Anxious

19. Interventions for anxiety • Relaxation • Challenging negative thoughts • Behavioral experiments • Allocate ‘worry time’ • Narrative strategies – worry box/worry monster • Cognitive strategies

20. Challenging negative thoughts – some helpful questions • Am I getting things out of proportion? • What happened the last time I was in this situation? • What would other people think in this situation? • Are my thoughts predicting the future in an unhelpful way? • What is the evidence for and against this thought?

21. Challenging negative thoughts – some helpful questions continued • Am I trying to read other people’s minds? • Is this just another example of my typical negative thinking?

22. What worked with Christine? • Normalising and psychoeducation • Working through anxiety book • Behavioral experiments and surveys • Questioning worst that could happen in a given situation and then planning how she could deal with this

23. UK residents report extensive damage following the earthquake

24. Outcomes • Engaging in new activities that previously would not have • Increasing social activities which had dropped due to fear of memory problems • Felt able to cope with Christmas (was not inviting people to her house but going to daughter instead) • Still held several theories re memory loss (including dementia) but didn’t worry about this

25. Case Study • What could you do to help Russell with his anxiety? • Design a behavioral experiment to help him achieve his goals

26. References • Greenberger and Padesky (1995) Mind over Mood • Bennett-Levy, J. et al (2004) Oxford guide to behavioural experiments in Cognitive Therapy • Mood gym (http://moodgym.anu.edu.au)