Therapy: Anxiety Management & Relaxation
Psychological techniques
for managing anxiety
Frank McDonald
Consultation-Liaison Psychologist
The Townsville Hospital
Queensland
Australia
Edvard Munch, 1896 - ‘Anxiety’
Overview
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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.
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
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
General comments on psychological mx
After Yerkes & Dodson 2
• 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
General comments on psychological mx
• Psychological treatments
(especially cognitivebehavioural 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
General comments on psychological mx
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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
Feelings & behaviour depend
on interpretation of events
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
i. Classical conditioning
(Ivan Pavlov) – learning by
association
Relaxation & exposure
(systematic desensitisation,
flooding & response
prevention) are behavioural
anxiety mx methods based
on classical conditioning
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
ii. 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
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
iii. 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
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 considerations in medically
managing anxiety
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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)?
General considerations in medically
managing anxiety
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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
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 shortterm 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’
Some psychological strategies for
managing anxiety – an overview
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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)
Fear
Relax
STOP
Relax
Relax
Relax
Relax
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Relax
STOP
Fear
The Principle of Exposure Therapy
Relax
STOP
Relax
Relax
Relax
Relax
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Relax
STOP
The Principle of Exposure Therapy
Some psychological strategies for
managing anxiety – an overview
Graded exposure (cont’d)
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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
Some psychological strategies for
managing anxiety – an overview
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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 antiworry statements/directions)
Worry-time/worry place (modifies
cues)
Meditation (trains “switching off” of
catastrophic thinking)
Assertiveness Training/ Social Skills
Training (counters social anxieties)
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?
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
Common Anxiety Disorders –
When & how to apply techniques
Psychological management PD+A
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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)
Common Anxiety Disorders –
When & how to apply techniques
Psychological management PD+A
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Regularising breathing rate – “slow & steady” 6 second cycle technique
Graded exposure to feared situations. See next slide
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)
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
Common Anxiety Disorders –
When & how to apply techniques
Psychological management GAD
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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/worryplace. Discuss examples
Support (guidance, advice/corrective
info, development of coping strategies)
Counselling
Stress management (relaxation,
meditation, exercise regimens that
improve stress recovery like ‘crossstressing’7)
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!
Common Anxiety Disorders –
When & how to apply techniques
Psychological management
OCD
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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
Anxiety acquisition, extinction
& spontaneous recovery curves
of classical conditioning
Common Anxiety Disorders –
When & how to apply techniques
Social Phobia
Features
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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
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
Common Anxiety Disorders –
When & how to apply techniques
Post-Traumatic Stress Disorder
Bali bomb survivor 2002
Features
1. Exposure to extreme trauma e.g.
that threatens life
2. Recurring images of the trauma
3. Distress triggered by similar events;
persistent hyperarousal
4. Avoidance of cues/reminders of
trauma
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
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
Common Anxiety Disorders –
When & how to apply techniques
Psychological management
Specific Phobia
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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)
Common Anxiety Disorders –
When & how to apply techniques
Structured problem solving
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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
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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 solutions
Put down all ideas, even bad ones. List the solutions without evaluation at this stage.
1. ___________________________________
2. _______________________________________
3. _______________________________________
4. _______________________________________
5. _______________________________________
6. _______________________________________
Common Anxiety Disorders –
When & how to apply techniques
• Step 3: Assess each possible solution
Quickly 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 solution
Choose the solution that can be carried out most easily to solve (or to
begin to solve) the problem.
Common Anxiety Disorders –
When & how to apply techniques
• Step 5: Plan how to carry out the best solution
List 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. ___________________________________
Common Anxiety Disorders –
When & how to apply techniques
Step 6: Review progress and ‘pat yourself on the back’ for any
progress
Focus 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?
__________________________________________________
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
Evidence for Psychological treatments
of anxiety
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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)
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
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
Evidence for Psychological treatments
of anxiety
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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)
1. psycho-education
2. verbal discussion techniques
3. imagery modification
4. attentional manipulations
5. exposure to feared stimuli
6. behavioural experiments, such
as manipulation of ‘safety
behaviours’ (e.g. avoidances)
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, straightforward desensitisation
procedures
Resources
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My web page
www.fmcdonald.com
(Copies of stress manuals, anxiety management h/o’s, Behavioural and Autosuggestion strategies for sleep, CBT for Psych Registrars presentation etc)
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Centre for Clinical Resources
http://www.cci.health.wa.gov.au/index.html
Lots of practical resources for pts and professionals alike covering a range of common
psychological issues. Concise but comprehensive, clearly and attractively presented.
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Australian Gov’t Health Insite
http://www.healthinsite.gov.au/topics/Causes_and_Treatments_of_Anxiety_Disorders
Resources
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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
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Treatment Manuals & Textbooks from CRUfAD
http://www.crufad.unsw.edu.au/books/treatment.htm
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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
Optional Self-test
1. 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?
2. Describe and discuss the various psychological treatments that are currently
used in the treatment of Panic Disorder with Agoraphobia.
3. 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?
4. 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?
Optional Self-test
5. 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.
Optional Self-test
6. 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?