Therapy: Anxiety Management & Relaxation

1. Therapy: Anxiety Management & Relaxation Psychological techniques for managing anxiety Frank McDonald Consultation-Liaison Psychologist The Townsville Hospital Queensland Australia Edvard Munch, 1896 - ‘Anxiety’

2. Some degree of acute anxiety is normal in most medical presentations. More chronic, Anxiety Disorders are the most common psychiatric condition, affecting 25% of adults at some point in their lives & 5%+/- of hospital pts1. Overview • Aim & Objective • General comments on psychological management • General considerations in medically managing anxiety • Psychological strategies for mx anxiety – brief survey • Class exercise on ‘instant’ strategies • Common anxiety disorders – what technique goes best with what condition? • Evidence for psychological treatments • Resources for practical applications • Optional self-test • References

3. Aim & Objective • Aim • To briefly survey some psychological strategies for mx of anxiety(Some – easily acquired or a natural part of medical roles that you’ll develop soon, if haven’t already. Others – need further training or ‘referring on’) • Objective • Students will be more aware of psychological methods of managing common anxiety presentations

4. After Yerkes & Dodson 2 General comments on psychological mx • Anxiety is a normal emotion in response to threat & a powerful motivator • Mild to moderate levels of anxiety improve the ability to cope, reactions become faster, understanding is better & responses are more appropriate   • On balance, acute moderate fear/anxiety a good thing • However, chronic high levels of anxiety reduce capacity to plan, make accurate judgments, carry out skilled tasks, & comprehend useful information – they can paralyze thinking & action

5. General comments on psychological mx • Psychological treatments (especially cognitive-behavioural therapies) can help restore mental health of anxious people & overcome debilitating effects of excessive anxiety   • Anxiety disorders are manageable, given skilful practitioner & hard-working patient • However, chronic & diffuse disorders like GAD are more difficult to treat successfully

6. Feelings & behaviour depend on interpretation of events General comments on psychological mx • Two main psychological interventions for anxiety disorders are the cognitive & the behavioural 1. Cognitive Therapy(termed Cognitive-Behaviour Therapy or CBT when, as is usual, combined with behavioural techniques)Cognitivists: “To feel differently, think differently. Distorted beliefs & other cognitive processes, like attention bias, contribute to psychopathology. Change internal processing of events.” Therapist & pt challenge & re-structure cognitive distortions & other unhelpful cognitions (specific thoughts, schema, spontaneous images, fantasies etc.) and/or modify attention e.g. via meditation

7. Previously neutral stimuli can, by association, evoke the same response as the original powerful one e.g. panic driving a car after an m.v.a.. Repeated, graded exposure to the newly fearful stimulus without the acquired association (of an accident), ‘extinguishes’ the learning General comments on psychological mx 2. Behaviour Therapy Behaviourists: “To feel differently, act differently. Change behaviour or manipulate environment.” - They apply principles of 3 main theories of learning • Classical conditioning(Ivan Pavlov) – learning by association Relaxation & exposure (systematic desensitisation, flooding & response prevention) are behavioural anxiety mx methods based on classical conditioning

8. Natural example of operant c’g Operant conditioning gone wrong! You positively & negatively reinforce child’s anxiety with such solicitousness General comments on psychological mx • Operant conditioning(B F Skinner) – learning by operating on the environment & its subsequent responses • No anxiety conditions treated by this alone. But rewards (positive reinforcement) & ending aversive experiences (negative reinforcement) help other approaches • E.g. more social assertion (less anxious withdrawal) brings pleasing responses from others & reduces loneliness. Increases chances of less anxious behaviour

9. Assertiveness training, social skills training, communication skills training, & problem-solving training - all used in behavioural & cognitive anxiety mx - rely heavily on modelling (& rehearsal++ to aid recall of the behaviour) General comments on psychological mx • Social (or observational) learning (Albert Bandura) • Learning by experiences in social relationships via negative & positive ‘modelling’ • Observing respected or significant others, & whether they are rewarded or punished, sets up expectations in observer, & results in behaviour changes • Bridges cognitive & behavioural theories. Learning can occur faster - by observation alone without changes in behaviour first, nor direct modification of cognitions

10. General considerations in medically managing anxiety • Treating anxiety part of mx of most medical conditions. Improves compliance and Q o L, reduces disability, decreases service reliance, improves outcomes e.g. less anxious surgical pts recover significantly sooner. Treating anxiety disorders, when associated with other psych disorders (p.d., depression, substance use), reduces suicide risk3 • Not always possible to engage mental health professional, so treating anxiety a core skill for doctors • So, what can you do immediately to help (i.e. without advanced training in CBT etc)?

11. General considerations in medically managing anxiety • Giving information, tailored to individual wishes, can go a long way to help most anxious pts. • Specifically, education about the nature of anxiety & its effects e.g. does not cause heart attacks in otherwise healthy pts4 • Counselling to help pt re-evaluate cause of anxiety symptoms, linking them to past or current psychosocial stresses - not some mysterious illness • Education to discourage avoidance/maintain routine activities despite anxiety

12. General considerations in medically managing anxiety • Anxiety associated with poor communication. Use of open questions, discussing psychological issues, empathising, summarising – while avoiding simple reassurance, ‘advice mode’ & leading questions –associated with greater disclosure & enduring change in anxious pts5 • Preparation for unpleasant procedures can give pts opportunity to plan short-term coping strategies • Exercise regimens (e.g. 10-15 week aerobic course)6 can ‘burn off’ hormones associated with anxiety for several hours • Practical help/referral e.g. budgeting, childcare, housing • As well, you can apply some of the following techniques. Others need further training or ‘referring on’

13. Some psychological strategies for managing anxiety – an overview • Relaxation techniques (for chronic autonomic arousal, “on edge” “uptight”, even when not exposed to fear) • Breathing retraining/ ’respiratory feedback’ for spontaneous & cued panics • Visual imagery like ‘safe, content place’ • Progressive (deep) muscle relaxation/isometric relaxation/ (better if combined with other techniques & practiced regularly) • Auto-suggestion/self-hypnosis • Flooding (‘face your fear’ principle – intense, no escape until settled, can be quicker, rarely used) • Graded exposure (‘face your fear’ principle – gradual, based on 0-10 or 100 pt Subjective Units of Disturbance Scale or ‘SUDS’ ratings of various situations)

14. Some psychological strategies for managing anxiety – an overview Graded exposure (cont’d) • Identify specific goals and break them into smaller, manageable steps • Initially, learn to master situations that cause mild anxiety • Progressively master situations that are associated with greater anxiety • Confront fears regularly & frequently • Emphasise reasonable habituation to anxiety (say 20-30/100 on subjective scale) for each exposure hierarchy item before progressing. Pt. doesn’t have to be perfectly relaxed – ‘manageable’ is fine • Can be therapist-assisted or self-directed

15. Some psychological strategies for managing anxiety – an overview • Problem-solving (‘brainstorming’ instead of ‘what if?’-ing) • Thought stopping (Stop! Technique. Disrupts ruminations/worry, combine w. other techniques) • Cognitive restructuring (challenging & modifying distressing thoughts, distortions, schemas, images. Works much better if pt does ‘homework’ diaries etc) • Distraction (e.g. how re-decorate room?, acute anxiety e.g. of GAD not PTSD, phobias, o’wise can interfere with exposure/need to face fears) • Coping statements (flashcards of anti-worry statements/directions) • Worry-time/worry place (modifies cues) • Meditation (trains “switching off” of catastrophic thinking) • Assertiveness Training/ Social Skills Training (counters social anxieties)

16. Some psychological strategies for managing anxiety – Class Exercise • Class Exercise: You have a pt suffering in-session anxiety. You ask “Which symptoms are most distressing?” to guide your intervention: • Physiologic symptoms (such as palpitations, tremors, tachypnea)? • Affective symptoms (unpleasant feelings, anxious affect)? • Cognitive symptoms (racing thoughts, poor concentration, thoughts of impending doom, loss of control fears)? • You start with one or two “coping skills” that are not too complex and can be applied immediately • If chief symptoms were physiologic and /or affective, what might you suggest? • If chief symptoms were cognitive, what might you suggest? • Script actual instructions. You may want to begin and end intervention with a SUDS. Why?

17. Common Anxiety Disorders – When & how to apply techniques Panic Disorder with Agoraphobia Features • Sudden attacks of fear or anxiety in situations of little danger • Symptoms of the "flight or fight" response, complicated by hyperventilation and worsened by the fear of collapse or death • Avoidance, for fear of panic, of situations from which escape is not possible or help is not available, typically public transport, travelling alone, crowded or lonely places

18. Common Anxiety Disorders – When & how to apply techniques Psychological management PD+A • Education about nature of disorder • Central feature of all anxiety disorders is that pts complain of physical symptoms of "flight or fight" response - rapid heart rate, need to overbreathe, tremor & shaking, nausea, sweating & focusing of attention (though men & women have different hormonal responses that produce behavioural nuances) • Education about meaning of these symptoms is key part of treatment (i.e. that they do not indicate physical illness, that they can be understood & controlled)

19. Common Anxiety Disorders – When & how to apply techniques Psychological management PD+A • Regularising breathing rate – “slow & steady” 6 second cycle technique • Graded exposure to feared situations. See next slide

20. Common Anxiety Disorders – When & how to apply techniques Example of a graded exposure hierarchy for Agoraphobic or Social Phobic pt Goal: To travel alone by bus to the city and back 1. Travelling one stop, quiet time of day (anxiety level 4/10) 2. Travelling two stops, quiet time of day 3. Travelling two stops, rush hour (anxiety level 6/10) 4. Travelling five stops, quiet time of day 5. Travelling five stops, rush hour (anxiety level 8/10) 6. Travelling all the way, quiet time of day 7. Travelling all the way, rush hour (anxiety level 10/10)

21. Common Anxiety Disorders – When & how to apply techniques Generalised Anxiety Disorder Features • Excessive anxiety or worry, occurring on most days for more than 6 months • The worry is out of proportion to the event, pervasive and excessive, difficult to control • Accompanied by muscle tension, hyperarousal and symptoms of the "flight or fight" response

22. Common Anxiety Disorders – When & how to apply techniques Psychological management GAD • Education about nature of disorder • Structured problem solving (See later slide) • Graded exposure to difficult situations (See earlier slide) • Cognitive-behaviour therapy e.g. written disputations, worry-time/worry-place. Discuss examples • Support (guidance, advice/corrective info, development of coping strategies) • Counselling • Stress management (relaxation, meditation, exercise regimens that improve stress recovery like ‘cross-stressing’7)

23. Common Anxiety Disorders – When & how to apply techniques Obsessive-Compulsive Disorder Features • Obsessions are thoughts, images or impulses that occur repeatedly, are intrusive & distressing & can't be supressed or neutralised. Not ego-syntonic like worry is • Compulsions are repetitive behaviours used to control or neutralise the obsessions and prevent the harm & reduce the anxiety, but which are excessive & disabling Does anal-retentive have a hyphen? This perfectionism of yours just isn’t good enough!

24. Anxiety acquisition, extinction & spontaneous recovery curves of classical conditioning Common Anxiety Disorders – When & how to apply techniques Psychological management OCD • Education about the nature of the disorder • Exposure + Response prevention / help to resist carrying out compulsions • Discuss case example of pt who has to continuously check kettle is not setting fire to kitchen • Relies on classical conditioning principle of extinction. See graph

25. Common Anxiety Disorders – When & how to apply techniques Social Phobia Features • Excessive & unreasonable fears of being the centre of attention in case of negative evaluation because of looking anxious or doing something embarrassing • Situations that could lead to scrutiny or evaluation (social functions, being in a crowd, speaking to others) are avoided or endured with intense anxiety

26. Common Anxiety Disorders – When & how to apply techniques Psychological management Social Phobia • Education about nature of disorder • Cognitive-behavioural strategies e.g. graded exposure therapy, rational disputation/Socratic questioning e.g. “evidence to support your idea?”, social skills training

27. Bali bomb survivor 2002 Common Anxiety Disorders – When & how to apply techniques Post-Traumatic Stress Disorder Features • Exposure to extreme trauma e.g. that threatens life • Recurring images of the trauma • Distress triggered by similar events; persistent hyperarousal • Avoidance of cues/reminders of trauma

28. Common Anxiety Disorders – When & how to apply techniques Psychological management PTSD • Education about the nature of the disorder • Exposure to the traumatic material - via graded exposure to cues (central component) - allows activation of fear, confronting it & thereby extinguishing it • Cognitive-behavioural strategies e.g. challenging & modifying their disruptive thoughts “how much time did you really have to try and save the other person?” & refer to time-distortion in recalling trauma, as discussed in education part; thought stopping, physical relaxation, role playing etc • Treatment of co-morbid disorders, especially depression, substance use

29. Common Anxiety Disorders – When & how to apply techniques Specific Phobia Features • Excessive fear of a specific object or situation e.g. flying, heights, animals, sight of blood, medical procedures such as injections • Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response e.g. Panic Attack • Person (many have a biological vulnerability) realises the fear is excessive or unreasonable

30. Common Anxiety Disorders – When & how to apply techniques Psychological management Specific Phobia • Education about nature of disorder • Graded exposure to difficult situations • Progressive muscle relaxation or other relaxation to counter autonomic arousal • ‘Applied muscle tension ’ in needle phobics to counter vasovagal/ fainting responses8)

31. Common Anxiety Disorders – When & how to apply techniques Structured problem solving • Best antidote to ‘catastrophising’/ ‘thinking the worst’ seen in worriers Very few, if any, worriers engage in problem solving • Do examples with pt during app’ts until manage on own • Give pt copies of work sheets for home practice.) Step 1: What is the problem/goal?Think about the problem/goal carefully, ask yourself questions. Then write down exactly what the problem/goal is. ___________________________________________________________________ Step 2: List all possible solutionsPut down all ideas, even bad ones. List the solutions without evaluation at this stage. 1. ___________________________________ 2. _______________________________________ 3. _______________________________________ 4. _______________________________________ 5. _______________________________________ 6. _______________________________________

32. Common Anxiety Disorders – When & how to apply techniques • Step 3: Assess each possible solutionQuickly go down the list of possible solutions and assess the main advantages and disadvantages of each one. • Step 4: Choose the "best" or most practical solutionChoose the solution that can be carried out most easily to solve (or to begin to solve) the problem.

33. Common Anxiety Disorders – When & how to apply techniques • Step 5: Plan how to carry out the best solutionList the resources needed and the major pitfalls to overcome. Practise difficult steps, make notes of information needed. • Step 1. ___________________________________Step 2. ___________________________________Step 3. ___________________________________Step 4. ___________________________________

34. Common Anxiety Disorders – When & how to apply techniques Step 6: Review progress and ‘pat yourself on the back’ for any progressFocus on achievement first. Identify what has been achieved, then what still needs to be achieved. Go through steps 1 to 6 again in the light of what has been achieved or learned. What has been achieved? __________________________________________________ What still needs to be done? __________________________________________________

35. Collaborative Management • Anxiety Disorders usually treated with counselling or psychotherapy or pharmacotherapy, as mono-therapies. No empirical support for combining (unlike depression)9,10. Bad news for pt who responds to neither rx • Milder forms may be effectively treated with cognitive or behaviour therapy alone, but more severe & persistent symptoms may need to start with pharmacotherapy. Sequential rather than concurrent therapies may be more successful. Currently under study11

36. Evidence for Psychological treatments of anxiety • Evidence suggests that CBT treatment ‘packages’ & Behavioural treatments (especially exposure–based) are among the most effective for anxiety disorders12,especially those Behavioural treatments that target avoidance • Avoidance rewards anxiety with relief & prevents “behavioural experiments”/testing of unreasonableness of fear • Level of evidence for CBT & Exposure-based approaches can reach Level 2 on 5 point scales (2 = RCT’s w/out double blind placebo control)

37. Evidence for Psychological treatments of anxiety • Limited evidence base for effectiveness of physical relaxation therapies, as sole rx, in relieving anxiety13,14 • However, can be used as an attention diversion strategy e.g. to aid sleep onset for worriers • With practice may help chronic tension levels causing muscle aches & insomnia

38. Evidence for Psychological treatments of anxiety • Impossible to provide Level 1, or ‘double blind’, psychological interventions in which neither pt nor therapist knows which intervention delivered • Arguable that best practice should also include Level 5 evidence – i.e. based on accumulated clinical wisdom of experienced experts15. • Even arguments against evidence-based principles in psychiatry, because its diagnostics are based on consensus & subtle symptom shifts, not experimentally derived knowledge16

39. Evidence for Psychological treatments of anxiety • In spite of evidence that CBT works, singularly effective ingredients not been identified for the anxiety disorders they improve. It’s the ‘package’ that works17 • Clark18 narrows down six active ingredients in Cognitive therapy that, combined, prove highly effective in Panic Disorder, Hypochondriasis, Social Phobia & PTSD (& possibly others) • psycho-education • verbal discussion techniques • imagery modification • attentional manipulations • exposure to feared stimuli • behavioural experiments, such as manipulation of ‘safety behaviours’ (e.g. avoidances)

40. Evidence for Psychological treatments of anxiety • Other factors such as unconscious processing in everyday thinking18 or the quality of the therapeutic relationship19 have also been shown to influence outcomes in Cognitive & exposure-based therapies • e.g. ‘warm’ therapists get better results than ‘cold’ therapists, even in mechanical, straight-forward desensitisation procedures

41. Resources • My web page www.fmcdonald.com (Copies of stress manuals, anxiety management h/o’s, Behavioural and Auto-suggestion strategies for sleep, CBT for Psych Registrars presentation etc) • Centre for Clinical Resources http://www.cci.health.wa.gov.au/index.htmlLots of practical resources for pts and professionals alike covering a range of common psychological issues. Concise but comprehensive, clearly and attractively presented. • Australian Gov’t Health Insite http://www.healthinsite.gov.au/topics/Causes_and_Treatments_of_Anxiety_Disorders

42. Resources • Causes & Treatments of Anxiety Disorders Clinical Research Unit for Anxiety Disorders (CRUfAD) http://www.crufad.com/cru_index.htm“It offers information so that some people can help themselves, it offers comprehensive information so that doctors can know the right treatment, and it offers information on the latest in our research.” A related website www.climategp.tv offers very high quality pt therapy and education about the management of anxiety and depression and other disorders. Access to the Net-based self mx programs can be ‘prescribed’ by a doctor or psychologist at a very moderate cost to pt or service • Treatment Manuals & Textbooks from CRUfADhttp://www.crufad.unsw.edu.au/books/treatment.htm • Guidelines for Assessing & Treating Anxiety Disorders A little dated & an NZ bias in places but very clear & comprehensive guide for practitioners. Some useful pt appendices. http://www.nzgg.org.nz/guidelines/dsp_guideline_popup.cfm?&guidelineID=38

43. Optional Self-test • A rather shy and introverted Engineering Student attends his GP surgery and says that he can't present his assignments in front of his seminar group. How can you help him? • Describe and discuss the various psychological treatments that are currently used in the treatment of Panic Disorder with Agoraphobia. • A 58 year old man attends medical outpatients for treatment following a recent myocardial infarction. He reports loss of interest and energy, has been unable to return to work, or to his previous interests. He complains of inability to concentrate, feeling ‘on edge’ most of the time and has been unable to sleep.What anxiety management strategies might be part of the overall approach to this man’s medical illness, anxiety and depression? • In a general practice you see many patients whose primary complaint is that they are "unable to sleep." Amongst the common reasons given for this presentation pts will say they “can’t switch off”. So you suspect cognitive anxiety causes. What can you suggest in terms of self-management?

44. Optional Self-test • You are following up a 52 year old woman following the birth of her second child. She attends your general practice expressing worries about the failure of her child (now aged 6 weeks) to feed properly, despite previous assurances that the child is well, and failure to detect any abnormality in the child. She appears tired and anxious, and states that she has been having problems with the behaviour of her other child now aged 2 years, with him becoming very demanding and irritable. She is married, works as a manager and has recently moved to the area from interstate. She is tearful, irritable, says that she is a "failure" as a mother, and complains of occasional feelings of severe panic that prevent her leaving the house alone. Discuss how you would proceed with the assessment of this woman's complaints and presentation. Include a discussion of your immediate steps in management, including a justification for the steps you take.

45. Optional Self-test • Mrs G.R. is a 43 year old divorcee who has been treated for symptoms of anxiety for the past 3 years with the benzodiazepine oxazepam. She comes to her GP complaining of an increase in her symptoms of anxiety and requests that her dose of oxazepam be raised from 30mg four times daily. There are no apparent stresses in her life. She adds that she is beginning to find it difficult to go to work. She appears to be “psychologically-minded” and is willing to try other approaches after you suggest this. How would you manage this patient?