Cognitive Behavioural
Therapy of Anxiety Disorders
MRCPsych Course 2011
Sally Standart
Anxiety Disorders (ICD-10)
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Phobias – agoraphobia, social, specific
Panic Disorder
Generalised Anxiety Disorder GAD
Obsessive Compulsive disorder OCD
Post-Traumatic Stress Disorder PTSD
Adjustment Disorders
Conversion Disorders
Somatoform Disorders
General principles
• People experience anxiety when they think situations are more
dangerous than they really are
• Goals of treatment are to help person consider alternative, less
frightening explanations
• Needs to be individualised, based on jointly derived alternative
explanation (i.e. formulation)
Safety behaviours
• Behaviours which the patient engages in to try to avoid a feared
outcome
• Safety Behaviours:
– Increase self-consciousness/self-focus
– Can increase feared symptoms (sweating, s etc
– May draw unwanted attention to self
– May contaminate the social situation
– Increase the belief that they are effective
– Prevent disconfirmation of this belief
Social Phobia
(Clark & Wells)
Social Situation
Activates assumptions
Perceived social danger
Processing of self
as social object
Safety Behaviours
Somatic & cognitive
symptoms
Social Phobia: step by step (Clark)
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Develop personalised model
Experiential learning exercise
Live feedback using audio/video
Attention training exercises
Interrogate the social environment using behavioural experiments
Deal with anticipatory anxiety & post mortem
Re-script early memories associated with mental imagery
Construct a more realistic social self-image
Tackle remaining assumptions
Model of OCD
(Wells & Matthews, 1994)
Trigger
Activates meta-beliefs
Appraisal of intrusion
Beliefs about rituals
Behavioural
response
Emotion
OCD: step by step (Salkovskis)
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Engage in assessment – make patient feel understood
Reach shared understanding of problems through formulation
Discuss alternative explanations
Engage in treatment – help patient choose to change
Help patient actively test alternative hypothesis and explore
implications
• Generalise change
• Relapse prevention
Meta-beliefs
Thoughts about the nature of intrusions
• Thought-Action Fusion (TAF)
– Thoughts are as bad as actions
– Thoughts of an event mean I have probably done it
– If I think something, then I will do it
• Thoughts can cause events (Thought-Event Fusion)
• Attentional strategy consequences
Beliefs about Rituals
• Positive beliefs concerning neutralisation
– Checking is the only way to feel better
– If I don’t stop this feeling, I’ll go mad
– If I complete _____ without thinking _____, everything will be OK
• Negative beliefs concerning neutralisation
– I have no control over ______
– Rituals can damage my body
Targets for Treatment
1. Meta-beliefs
– Via appraisal of intrusion
– Is this my OCD or an important thought?
– e.g. sparrows on the way to work…..
2. Beliefs about rituals
3. Behavioural responses
– As a route to challenging 1 & 2.
Normalising
• Unacceptable intrusions are a normal occurrence (Rachman & Da
Silva work in 1970s)
– Problem lies in interpretation or appraisal of them
• Useful to worry about some things to some extent
– Problem lies in belief that harm may arise if worries not
controlled or counteracted in some way
• Some precautionary measures can be useful in some situations
– Problem arises when person tries too hard (to get rid of thought,
prevent harm, become certain, be clean etc) so……THE
SOLUTION BECOMES THE PROBLEM…….
Behavioural Experiments
• How can we test the validity of this belief?
• If you changed (behaviour), what would be
the outcome if (belief) was true?
• Describe in detail (time course, severity)
the predicted outcome
Behavioural experiment record
sheet
Situation
Prediction Experiment Outcome What I
learned
Describe
situation in
detail
What exactly
did you think
would
happen?
How would
you know?
Rate belief
What did you
do to test the
prediction?
What
actually
happened?
Was your
prediction
correct?
Balanced
view
Re-rate belief
How likely is
what you
predicted to
happen in the
future?
Exposure & Response Prevention
ERP
• Define belief to be tested
• Decide on exposure - ? graded hierarchy
– May need to go beyond non-obsessional to anti-obsessional
– Therapist modelling in early experiments
– Maintain balance of responsibility with patient
• Identify typical/likely response to feared stimulus
• Rate anxiety/discomfort/fear before, during and after exposure
• Record outcome
• Repeat & review
Overcoming Resistance
• Pros and cons of existing behaviour vs new
behaviour
• Guarantees……..
• Goal setting to aid motivation
• Involve significant others
• Be aware of your own behaviour as a therapist –
are you inadvertently facilitating the patient’s
avoidance?
Relapse Prevention
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‘Discharge’ = final big experiment
‘Setback’ vs relapse
Utilise setbacks in course of therapy for learning
Discuss the future and anticipate problems
Keep long term goals in focus
Therapy ‘blueprint’ and action plan
Consider holding back one appointment for review after longer
period
Resources/References
• Cognitive Therapy of Anxiety Disorders: A
practice manual and conceptual guide.
Adrian Wells
• Overcoming Anxiety. Chris Williams