2Overview Aim & Objective General comments on psychological management General considerations in medically managing anxietyPsychological strategies for mx anxiety – brief surveyClass exercise on ‘instant’ strategiesCommon anxiety disorders – what technique goes best with what condition?Evidence for psychological treatmentsResources for practical applicationsOptional self-testReferencesSome degree of acute anxiety is normal in most medicalpresentations. More chronic, Anxiety Disorders are themost common psychiatric condition, affecting 25%of adults at some point in their lives & 5%+/- of hospital pts1.
3Aim & ObjectiveAimTo 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’)ObjectiveStudents will be more aware of psychological methods of managing common anxiety presentations
4General comments on psychological mx Anxiety is a normal emotion in response to threat & a powerful motivatorMild 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 thingHowever, chronic high levels of anxiety reduce capacity to plan, make accurate judgments, carry out skilled tasks, & comprehend useful information – they can paralyze thinking & actionAfter Yerkes & Dodson 2How might the normal response of mild anxiety to physical illness be a good thing for pts? When or how might it become a bad thing ?
5General 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 patientHowever, chronic & diffuse disorders like GAD are more difficult to treat successfully
6General comments on psychological mx Two main psychological interventions for anxiety disorders are the cognitive & the behavioural1. 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 meditationFeelings & behaviour dependon interpretation of events
7General comments on psychological mx 2. Behaviour TherapyBehaviourists: “To feel differently, act differently. Change behaviour or manipulate environment.”- They apply principles of 3 main theories of learningClassical conditioning (Ivan Pavlov) – learning by associationRelaxation & exposure (systematic desensitisation, flooding & response prevention) are behavioural anxiety mx methods based on classical conditioningPreviously 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
8General comments on psychological mx Natural example of operant c’gOperant conditioning (B F Skinner) – learning by operating on the environment & its subsequent responsesNo anxiety conditions treated by this alone. But rewards (positive reinforcement) & ending aversive experiences (negative reinforcement) help other approachesE.g. more social assertion (less anxious withdrawal) brings pleasing responses from others & reduces loneliness. Increases chances of less anxious behaviourOperant conditioning gone wrong!You positively & negativelyreinforce child’s anxiety with suchsolicitousness
9General 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 changesBridges cognitive & behavioural theories. Learning can occur faster - by observation alone without changes in behaviour first, nor direct modification of cognitionsAssertiveness training, social skillstraining, communication skillstraining, & problem-solving training- all used in behavioural & cognitiveanxiety mx - rely heavily on modelling(& rehearsal++ to aid recall of the behaviour)
10General 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 risk3Not always possible to engage mental health professional, so treating anxiety a core skill for doctorsSo, what can you do immediately to help (i.e. without advanced training in CBT etc)?
11General 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 pts4Counselling to help pt re-evaluate cause of anxiety symptoms, linking them to past or current psychosocial stresses - not some mysterious illnessEducation to discourage avoidance/maintain routine activities despite anxiety
12General 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 pts5Preparation for unpleasant procedures can give pts opportunity to plan short-term coping strategiesExercise regimens (e.g week aerobic course)6 can ‘burn off’ hormones associated with anxiety for several hoursPractical help/referral e.g. budgeting, childcare, housingAs well, you can apply some of the following techniques. Others need further training or ‘referring on’
13Some 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 panicsVisual imagery like ‘safe, content place’Progressive (deep) muscle relaxation/isometric relaxation/ (better if combined with other techniques & practiced regularly)Auto-suggestion/self-hypnosisFlooding (‘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)
14Some psychological strategies for managing anxiety – an overview Graded exposure (cont’d)Identify specific goals and break them into smaller, manageable stepsInitially, learn to master situations that cause mild anxietyProgressively master situations that are associated with greater anxietyConfront fears regularly & frequentlyEmphasise 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 fineCan be therapist-assisted or self-directed
15Some 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)
16Some 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 immediatelyIf 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?
17Common Anxiety Disorders – When & how to apply techniques Panic Disorder with AgoraphobiaFeaturesSudden attacks of fear or anxiety in situations of little dangerSymptoms of the "flight or fight" response, complicated by hyperventilation and worsened by the fear of collapse or deathAvoidance, 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
18Common Anxiety Disorders – When & how to apply techniques Psychological management PD+AEducation about nature of disorderCentral 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)
19Common Anxiety Disorders – When & how to apply techniques Psychological management PD+ARegularising breathing rate – “slow & steady” 6 second cycle techniqueGraded exposure to feared situations. See next slide
20Common Anxiety Disorders – When & how to apply techniques Example of a graded exposure hierarchyfor Agoraphobic or Social Phobic ptGoal: To travel alone by bus to the city and back1. Travelling one stop, quiet time of day (anxiety level 4/10)2. Travelling two stops, quiet time of day3. Travelling two stops, rush hour (anxiety level 6/10)4. Travelling five stops, quiet time of day5. Travelling five stops, rush hour (anxiety level 8/10)6. Travelling all the way, quiet time of day7. Travelling all the way, rush hour (anxiety level 10/10)
21Common Anxiety Disorders – When & how to apply techniques Generalised Anxiety DisorderFeaturesExcessive anxiety or worry, occurring on most days for more than 6 monthsThe worry is out of proportion to the event, pervasive and excessive, difficult to controlAccompanied by muscle tension, hyperarousal and symptoms of the "flight or fight" response
22Common Anxiety Disorders – When & how to apply techniques Psychological management GADEducation about nature of disorderStructured 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 examplesSupport (guidance, advice/corrective info, development of coping strategies)CounsellingStress management (relaxation, meditation, exercise regimens that improve stress recovery like ‘cross-stressing’7)
23Common Anxiety Disorders – When & how to apply techniques Obsessive-Compulsive DisorderFeaturesObsessions are thoughts, images or impulses that occur repeatedly, are intrusive & distressing & can't be supressed or neutralised. Not ego-syntonic like worry isCompulsions are repetitive behaviours used to control or neutralise the obsessions and prevent the harm & reduce the anxiety, but which are excessive & disablingDoes anal-retentivehave a hyphen?This perfectionism of yoursjust isn’t good enough!
24Common Anxiety Disorders – When & how to apply techniques Psychological management OCDEducation about the nature of the disorderExposure + Response prevention / help to resist carrying out compulsionsDiscuss case example of pt who has to continuously check kettle is not setting fire to kitchenRelies on classical conditioning principle of extinction. See graphAnxiety acquisition, extinction& spontaneous recovery curvesof classical conditioning
25Common Anxiety Disorders – When & how to apply techniques Social PhobiaFeaturesExcessive & unreasonable fears of being the centre of attention in case of negative evaluation because of looking anxious or doing something embarrassingSituations that could lead to scrutiny or evaluation (social functions, being in a crowd, speaking to others) are avoided or endured with intense anxiety
26Common Anxiety Disorders – When & how to apply techniques Psychological managementSocial PhobiaEducation about nature of disorderCognitive-behavioural strategiese.g. graded exposure therapy,rational disputation/Socratic questioning e.g. “evidence to support your idea?”, social skills training
27Common Anxiety Disorders – When & how to apply techniques Post-Traumatic Stress DisorderFeaturesExposure to extreme trauma e.g. that threatens lifeRecurring images of the traumaDistress triggered by similar events; persistent hyperarousalAvoidance of cues/reminders of traumaBali bomb survivor 2002
28Common Anxiety Disorders – When & how to apply techniques Psychological management PTSDEducation about the nature of the disorderExposure to the traumatic material- via graded exposure to cues (central component)- allows activation of fear, confronting it & thereby extinguishing itCognitive-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 etcTreatment of co-morbid disorders, especially depression, substance use
29Common Anxiety Disorders – When & how to apply techniques Specific PhobiaFeaturesExcessive fear of a specific object or situatione.g. flying, heights, animals, sight of blood, medical procedures such as injectionsExposure to the phobic stimulus almost invariably provokes an immediate anxiety response e.g. Panic AttackPerson (many have a biological vulnerability) realises the fear is excessive or unreasonable
30Common Anxiety Disorders – When & how to apply techniques Psychological management Specific PhobiaEducation about nature of disorderGraded exposure to difficult situationsProgressive muscle relaxation or other relaxation to counter autonomic arousal‘Applied muscle tension ’ in needle phobics to counter vasovagal/ fainting responses8)
31Common Anxiety Disorders – When & how to apply techniques Structured problem solvingBest antidote to ‘catastrophising’/ ‘thinking the worst’ seen in worriers Very few, if any, worriers engage in problem solvingDo examples with pt during app’ts until manage on ownGive 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 ___________________________________2. _______________________________________3. _______________________________________4. _______________________________________5. _______________________________________6. _______________________________________
32Common 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.
33Common 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. ___________________________________
34Common 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? __________________________________________________
35Collaborative 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 rxMilder 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
36Evidence 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 avoidanceAvoidance rewards anxiety with relief & prevents “behavioural experiments”/testing of unreasonableness of fearLevel of evidence for CBT & Exposure-based approaches can reach Level 2 on 5 point scales (2 = RCT’s w/out double blind placebo control)
37Evidence for Psychological treatments of anxiety Limited evidence base for effectiveness of physical relaxation therapies, as sole rx, in relieving anxiety13,14However, can be used as an attention diversion strategy e.g. to aid sleep onset for worriersWith practice may help chronic tension levels causing muscle aches & insomnia
38Evidence for Psychological treatments of anxiety Impossible to provide Level 1, or ‘double blind’, psychological interventions in which neither pt nor therapist knows which intervention deliveredArguable 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
39Evidence 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 works17Clark18 narrows down six active ingredients in Cognitive therapy that, combined, prove highly effective in Panic Disorder, Hypochondriasis, Social Phobia & PTSD (& possibly others)psycho-educationverbal discussion techniquesimagery modificationattentional manipulationsexposure to feared stimulibehavioural experiments, such as manipulation of ‘safety behaviours’ (e.g. avoidances)
40Evidence 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 therapiese.g. ‘warm’ therapists get better results than ‘cold’ therapists, even in mechanical, straight-forward desensitisation procedures
41Resources 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 Lots 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
42ResourcesCauses & Treatments of Anxiety Disorders Clinical Research Unit for Anxiety Disorders (CRUfAD) “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 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 serviceTreatment Manuals & Textbooks from CRUfADGuidelines for Assessing & Treating Anxiety DisordersA little dated & an NZ bias in places but very clear & comprehensive guide for practitioners. Some useful pt appendices.
43Optional Self-testA 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?
44Optional Self-testYou 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.
45Optional Self-testMrs 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?