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Treatments for Anxiety Stacy Shaw Welch, PhD Anxiety and Stress Reduction Center (ASRC) of Seattle June 2, 2010 FCAP Seminar Series / Partners for our.

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Presentation on theme: "Treatments for Anxiety Stacy Shaw Welch, PhD Anxiety and Stress Reduction Center (ASRC) of Seattle June 2, 2010 FCAP Seminar Series / Partners for our."— Presentation transcript:

1 Treatments for Anxiety Stacy Shaw Welch, PhD Anxiety and Stress Reduction Center (ASRC) of Seattle June 2, 2010 FCAP Seminar Series / Partners for our Children

2 Overview Part 1 – Understanding anxiety Part 2 – Treating anxiety: First line treatment approaches for anxiety Part 3 – Concepts of Modular Treatment (moving from Evidence Based Treatment to Evidence Based Practice) Part 4 - Introduction to Modules for Anxiety Treatment

3 Fear, Anxiety, and Anxiety Disorders

4 What is anxiety? Fear: focused response to a known or definite threat Fight or flight response Necessary for survival Anxiety: fear response in the absence of clear danger (anticipation or possibility) Universal experience / wide range of normal Can be useful/ functional

5 What is an anxiety disorder? Persistent anxiety over time around situations that are not objectively dangerous / anxiety not appropriate to developmental level Causes Marked distress Impairment in functioning Note: this can be obvious or more subtle in children (e.g., family system is organized around child’s anxiety)

6 Anxiety vs. Anxiety Disorder More a matter of degrees Example of separation anxiety: Normal / functional at specific developmental stages Some children show increased S.A. as a result of traumatic conditioning Some children show increased S.A. with no traumatic conditioning Some children would have such severe or longlasting symptoms that it would meet criteria for a disorder

7 Anxiety disorders Separation anxiety disorder Specific phobia Social phobia Panic disorder/agoraphobia Generalized anxiety disorder (GAD) Posttraumatic stress disorder (PTSD)/ Acute stress disorder (ASD) Obsessive compulsive disorder (OCD)

8 Development of Anxiety Biology + learning Genetics, temperament clearly influence who becomes anxious Environment powerful source of learning and continued “wiring” of the brain to either anticipate lack of control and danger or safety and resources to cope Transaction between the two continues over the lifespan –this is the tragedy and great hope

9 Development of Anxiety Another important transaction: the interaction of anxious behaviors and the environment Anxiety “pulls” for certain behaviors from the environment These environmental responses can further reinforce anxiety and prevent corrective learning experiences

10 Treating Anxiety: Brief Review of Research

11 Treatment Two main treatment approaches for children, teens and adults CBT – by far most well researched and effective treatment for anxiety. Should be first-line intervention, combined with meds for moderate or severe disorder. Medication – SSRIs first, then augmentation strategies

12 What is CBT? - Skills based, problem-solving, very practical approach to emotionally driven problems/behaviors -Patients learn to take “bite-sized” small steps towards health -Biopsychosocial model as opposed to purely biomedical model Should include at least 4 elements: education/monitoring, tools to calm physiology, cognitive restructuring, exposure

13 What kinds of problems can it be used for? Think behavior change, esp. emotionally driven behaviors Depression * Anxiety disorders** Unexplained medical illness / somatization Chronic pain management Eating disorders (bulimia and binge eating) Insomnia (primary and secondary) Addictions Non-adherence to medical recommendations Lifestyle / Behaviors linked to chronic disease care (physical activity, diet, social support, medications, etc.) Child internalizing and depressive disorders** Marital distress Anger

14 Specific Approaches to Anxiety Treatment Adults: a manual (or two, or three) for each anxiety disorder Children: Not much until 1980’s (DSM-III) Early approaches: adult techniques and theories with child- language Major studies / treatments to know: CBT for anxiety: “Coping Cat”, “Coping Koalla (Kendall, Barrett) Talking Back to OCD: ERP (March), POTS CAMS (meds plus CBT) TFCBT – Trauma – focused CBT Modular treatments emphasizing exposure (Chorpita)

15 Coping Cat (Kendall et al, 1994, 1997) 16-session CBT program for overanxious (GAD), separation, social anxiety, adjustment problems “Coping Cat” 7-14, “Cat” % no longer met anxiety disorder criteria Gains maintained at 1 year / 3 year follow up (5% waitlist) “ F.E.A.R” plan takes children through elements of CBT including techniques to calm their bodies, cognitive restructuring, exposure, and rewards

16 CBT, Meds, and combination: what’s best? CAMS study (Dec. 2008) 488 Children, ages 7 – 17 Primary diagnoses of SAD, GAD, social phobia Randomized to 14 sessions of CBT, up to 200 mg. of sertraline, combination therapy, or placebo Results: “much improved” or “very much improved” on CGI CBT alone: 59.7% Sertraline alone: 54.9% Placebo: 23.7% Combination: 80.7%

17 Conceptual framework for Modular Treatment of Anxiety

18 Modular treatment Addressing what happens when you try to apply evidence based treatment in community settings with Complex clients Complex situations Logistical challenges (e.g., time)

19 Evidence-based treatments vs. practice Evidence-based treatments “interventions or techniques that have produced therapeutic change in controlled trials” (Kazdin, 2008) Evidence-based practice “clinical practice that is informed by evidence about interventions, clinical expertise, and patient needs, values, and preferences and their integration in decision making about individual care” (Kazdin, 2008)

20 Protocol-based treatment Strong trend over the last 25 years toward the development of standardized, protocol- based treatments (i.e., treatment manuals) Protocol characteristics: Disorder specific Step-by-step list of interventions Same set of procedures across clients Dissemination and training is generally needed for each protocol

21 Pros and cons Pros Significant advances in the scientific study of psychotherapy (treatments are replicable) Improved treatment outcomes Greater consistency and quality of care Cons Problems with dissemination Overlap and redundancy across protocols Multiple protocols for the same disorder Don’t address co-morbidity Decreased flexibility in treatment Encourage disorder-specific thinking

22 Modular-based treatment Emerging trend in recent years toward more modular, flexible approaches to treatment Modular approaches provide a set of overarching principles and a set of evidence- based interventions (“modules”) Not all modules are necessarily used with each client and the order of modules may vary from client to client Decisions about which modules to use and in what order are based on the unique symptom patterns of each client

23 Modular treatment and anxiety Anxiety disorders lend themselves well to a modular treatment approach because… They share many of the same features and symptoms A CBT conceptualization of anxiety can be applied across the disorders There is considerable overlap in the interventions that comprise the treatment protocols for the various disorders Modular approaches have been developed for treating anxiety in children/adolescents (Chorpita, 2006) and somewhat with adults (Barlow et al., 2004; Sullivan et al., 2007)

24 Basic CBT model of anxiety Physical sensations ( physiological arousal) Behaviors (avoidance, safety behaviors) Thoughts (perception of threat) Anxiety

25 Safety behaviors Anxious people often engage in a range of behaviors to make themselves feel safer when they cannot avoid anxious situations These behaviors are attempts to neutralize feelings of anxiety Although these behaviors can facilitate functioning, they also prevent recovery Examples Reassurance seeking Over-preparation Behavioral rituals Safety cues/objects

26 Integrated CBT Model of Anxiety Disorders Fear Stimulus (trigger or cue) Misinterpretation of Threat Anxiety Avoidant Coping (primary and secondary) Absence of Corrective Experience and Learning Pre-existing Beliefs Environmental Factors

27 Components of the model Fear stimulus/trigger Anxiety is almost always cued Misinterpretation of threat Primary cognitive distortions in anxiety (1) Overestimating the likelihood of negative outcomes (2) Catastrophizing Avoidant coping Primary avoidance – avoiding triggers altogether Secondary avoidance – engaging in safety behaviors when complete avoidance is not possible Absence of corrective learning New learning does not occur and the fear is maintained (and often strengthened)

28 Separation anxiety disorder Fear Stimulus (trigger or cue) Misinterpretation of Threat Anxiety Avoidant Coping (primary and secondary) Absence of Corrective Experience and Learning - Separating from parent at school. - Going to a friend’s house for a sleep-over. - My mom/dad might die. - Something bad might happen to my mom/dad. - Panic symptoms, crying - Primary avoidance: Refuse to leave house/car; call home to be picked up - Secondary avoidance: Separates but only if can call parent repeatedly to seek reassurance that he/she is okay; has to carry cell phone at all times

29 Specific phobia (flying) Fear Stimulus (trigger or cue) Misinterpretation of Threat Anxiety Avoidant Coping (primary and secondary) Absence of Corrective Experience and Learning - Needing to fly for a business trip. - Needing to fly for a family vacation. - Something will go wrong with the plane. - The plan will crash and I will die. - Increased heart rate, shallow breathing - Primary avoidance: Avoid going on the trip; get someone else to attend the business meeting; family drives to vacation spot instead of flying - Secondary avoidance: Sit next to “safe” person; distract self for entire flight; seek reassurance from others about airline safety; drink alcohol or take Xanax before/during the flight (adults)

30 Social phobia Fear Stimulus (trigger or cue) Misinterpretation of Threat Anxiety Avoidant Coping (primary and secondary) Absence of Corrective Experience and Learning - Having to give a presentation in front of the class. - Needing to ask a question in a store. - I will sound stupid. My mind will go blank. - I will be an inconvenience. He will be annoyed. - Increased heart rate, sweating, lightheaded - Primary avoidance: Skip class; avoid asking the question - Secondary avoidance: Look down at notes during the entire presentation; talk quickly; over-prepare for presentation; overly apologetic when asking question

31 Panic disorder Fear Stimulus (trigger or cue) Misinterpretation of Threat Anxiety Avoidant Coping (primary and secondary) Absence of Corrective Experience and Learning - Exercising and heart rate starts to increase. - I am going to have a heart attack. - I am going to pass out. - Panic symptoms (increased heart rate, shallow breathing, sweating, dizziness) - Primary avoidance: Stop exercising; leave the gym - Secondary avoidance: Repeatedly check heart rate; call doctor office; go to urgent care center; seek reassurance from friend; carry water and cell phone at all times at gym

32 GAD Fear Stimulus (trigger or cue) Misinterpretation of Threat Anxiety Avoidant Coping (primary and secondary) Absence of Corrective Experience and Learning - Trying to call spouse and he/she is not answering. - Something must have happened. - He/she was in an accident. - Restlessness, muscle tension, increased heart rate - Primary avoidance: N/A - Secondary avoidance: Repeatedly calling spouse at multiple numbers (work, cell phone) until reaching him/her; keep busy and try to distract self until spouse is home

33 PTSD (sexual assault) Fear Stimulus (trigger or cue) Misinterpretation of Threat Anxiety Avoidant Coping (primary and secondary) Absence of Corrective Experience and Learning - Walking home from bus stop after work at dusk. - I am not safe. - Someone could assault/rape me on the way home. - Increased heart rate, shallow breathing, upset stomach - Primary avoidance: Avoid taking the bus; drive to and from work; call someone for a ride - Secondary avoidance: Have someone walk with him/her between bus stop and home; talk on cell phone during entire walk home; walk quickly; carry pepper spray in hand during walk

34 OCD (checking) Fear Stimulus (trigger or cue) Misinterpretation of Threat Anxiety Avoidant Coping (primary and secondary) Absence of Corrective Experience and Learning - Turning off the stove after cooking breakfast. - What if I left the stove on? - It could burn down the house. - Increased heart rate - Primary avoidance: Avoid eating breakfast foods that require using the stove - Secondary avoidance: Repeatedly check the stove before leaving the house; drive back home mid- day from work to check the stove; call neighbor to check on the house; mentally review memory of turning off the stove throughout the day

35 Shared processes to target There are a set of anxiety processes that are important to target regardless of which anxiety disorder is being treated Maladaptive thoughts that contribute to perceptions of threat in safe situations Physiological reactivity in response to fear triggers Avoidance behaviors that prevent the habituation of fear Safety behaviors that prevent new learning Problematic reinforcement of anxiety by the environment

36 Good news… We have very effective CBT interventions for the processes common to the anxiety disorders! Process/problemIntervention Misperception of threat Cognitive restructuring Physiological reactivity Relaxation skills Avoidance behaviors Exposure** Safety behaviors Response prevention Reinforcement of anxiety by environment Contingency management

37 Modular treatment for anxiety A modular CBT approach to treating anxiety involves… Assessing which anxiety processes are most prominent for each client Selecting the evidence-based interventions (“modules”) that are effective for treating these processes Sequencing these modules to address the unique characteristics of each client and his/her environment

38 CBT “modules” for anxiety Psychoeducation Self-monitoring Relaxation skills Cognitive restructuring Response prevention Exposure* Parenting techniques Changing environmental contingencies/responses Relapse prevention Others: social skills, emotion regulation, behavioral activation, motivational interviewing…. Flexible modules

39 Flowchart for a standard manualized CBT protocol Learning about Anxiety Relaxation Cognitive Restructuring Exposure Rewards / Practice Maintenance Fear Ladder Finish

40 Modular CBT protocol – (Just get to Exposure) Fear Ladder Learning about Anxiety child ready to practice? in vivo possible? Imaginal Exposure In Vivo Exposure more items to practice? Maintenancee Finish no yes no Interference no

41 Modular flowchart for treatment planning Fear Ladder Learning about Anxiety child ready to practice? in vivo possible? Imaginal Exposure In Vivo Exposure more items to practice? MaintenanceFinish moderate disruptive behavior? parents rewarding avoidance? low motivation? other mild disruptive Behavior? negative beliefs or depression? social skills deficits? troubleshoot Time-Out Cognitive Restructuring: Probability Active Ignoring Cognitive Restructuring: STOP bright, verbal, or older? Cognitive Restructuring: Catastrophic Rewards Social Skills: Meeting People Social Skills: Nonverbal no yes no

42 Modular flowchart for treatment planning Fear Ladder Learning about Anxiety child ready to practice? in vivo possible? Imaginal Exposure In Vivo Exposure more items to practice? MaintenanceFinish moderate disruptive behavior? parents rewarding avoidance? slow motivation? other mild disruptive Behavior? negative beliefs or depression? social skills deficits? troubleshoot Time-Out Cognitive Restructuring: Probability Active Ignoring Cognitive Restructuring: STOP bright, verbal, or older? Cognitive Restructuring: Catastrophic Rewards Social Skills: Meeting People Social Skills: Nonverbal no yes no

43 CBT “modules” for anxiety Psychoeducation Self-monitoring Relaxation skills Cognitive restructuring Response prevention Exposure* Parenting techniques Changing environmental contingencies/responses Relapse prevention Others: social skills, emotion regulation, behavioral activation, motivational interviewing…. Flexible modules

44 Psychoeducation Key to helping clients understand their symptoms and the treatment model Psychoeducation should include both: Disorder specific information Review of the integrated CBT model of anxiety Helpful to fill out the model with the client using examples from his/her life Kids- maps, posters, etc. Could be used for anxiety disorder or “normal” anxiety (will be validating if not anxiety reducing) Could be used for parents dealing with anxiety, even without anxiety disorder

45 Integrated Model of Anxiety - Client Handout Fear Stimulus (trigger or cue) Misinterpretation of Threat Anxiety Avoidant Coping (primary and secondary) Absence of Corrective Experience and Learning Pre-existing Beliefs Environmental Factors

46 Self-monitoring Critical part of problem/ symptom assessment Helps client recognize the different components of their anxious reactions (“anxiety is not a lump”) Helps clients identify patterns in responses Elements of self-monitoring for anxiety include: Triggers/cues for anxiety Intensity ratings for anxiety (SUDS) Physical sensations Anxious thoughts Anxious behaviors (avoidance, safety behaviors) Young kids would do with caretaker

47 Self-monitoring example – social phobia Situation/triggerBoss asked me a question in a meeting Intensity of anxiety (0-10)5 Physical sensations/ other symptoms Sweating, lightheaded, upset stomach Anxious thoughts (words or images) “I am going to freeze up,” “I will sound like an idiot” Anxious behaviors (e.g., avoidance, safety behaviors, rituals) Gave a short answer; avoided eye contact; took a drink of water; mental retracing after

48 Self-monitoring example - panic Situation/triggerStanding in line at a store Intensity of anxiety (0-10)7 Physical sensations/ other symptoms Increased heart rate, shallow breathing, sweating Anxious thoughts (words or images) “I am going to have a panic attack,” “I won’t be able to get out of here in time” Anxious behaviors (e.g., avoidance, safety behaviors, rituals) Put my merchandise down and left the store; went to sit on a bench to calm down; took a Xanax

49 Self-monitoring example - OCD Situation/triggerHitting a bump in the road while driving Intensity of anxiety (0-10)9 Physical sensations/ other symptoms Increased heart rate Anxious thoughts (words or images) “What if I hit someone with my car?” Anxious behaviors (e.g., avoidance, safety behaviors, rituals) Drove around the block 4 times to check for injured pedestrians; mental retracing

50 Relaxation Relaxation skills target physiological reactivity associated with anxiety and worry Two main skills are Diaphragmatic breathing – targets acute panic/anxiety reactions Progressive muscle relaxation – targets chronic muscle tension associated with ongoing anxiety/worry Important to be realistic about how effective these skills are in reducing anxiety Could be taught for anxiety disorder or “normal” anxiety Creative ways to teach children (bubbles, snake, tire)

51 Relaxation Disorder specific recommendations Breathing re-training is a standard part of treatment for panic disorder PMR is a standard part of treatment for GAD Neither tends to work that well for OCD General recommendations Consider using with children and adolescents regardless of disorder Consider using with adults regardless of disorder when physiological symptoms are prominent and/or interfere with treatment Coach clients not to use relaxation skills during exposure exercises

52 Exposure Exposure is staying present with the feared stimulus long enough for new learning to occur (assuming that fear is not really dangerous)

53 Habituation and anxiety Anxiety Time

54 Exposure Three golden rules of exposure: 1. Fears are faced gradually, moving from least to most difficult 2. The client must stay in the feared situation long enough to learn that the bad things s/he fears will not happen. If withdrawal occurs to quickly-fear can increase 3. Practice and repetition are the keys to success If withdrawal occurs to quickly-fear can increase

55 Exposure Process of exposure is similar across the anxiety disorders, what varies is the fear trigger Separation anxiety – separation from caregiver Specific phobia – feared object/ situation Social phobia – social/performance situations Panic/agoraphobia – physical sensations of panic/avoided activities and situations GAD – worry scenarios/images and worry triggers PTSD – trauma memories and triggers OCD – triggers for obsessions and obsessive thoughts themselves

56 Exposure: Build a Hierarchy First, externalize anxiety Teach children how to identify and rate anxiety Fear thermometer / worry scale Anxiety list, “bravery ladder”, map Case example: “Jayden”, 9 year old boy with GAD, mild OCD Very significant worries in a wide range of areas – academic, medical, social, getting hurt, making any mistake Adopted at age 4 out of foster care system, very early abuse/neglect Significant risk and protective factors

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58 Example: Jayden, GAD SituationWorry Scale HighGetting a shot Teacher yelling at me Making mistakes on tests Falling and getting hurt at school Forgetting my homework Seeing blood Thinking about robbers Getting a bad grade Going to a new place MediumBeing late for school Forgetting a library book Making a mistake on homework Meeting new people Laundry machine LowChatting at school Playdates 4343

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63 Exposure hierarchy example – separation anxiety SUDsTrigger 10Going to an overnight camp 9Spending the night at a friend’s house 8Staying with grandma – both parents out of town overnight 7One parent out of town overnight 52 hour play-date (no parents present) 31 hour play date (no parents present) 1Playing alone in room (parents outside in yard)

64 Exposure hierarchy example – PTSD (car accident) SUDsTrigger 10Driving on freeway where accident happened 8Talking about the memory of the accident 7Watching a car accident in a movie/TV show 5Driving on a busy road at rush hour 4Driving on a busy road not at rush hour 3Driving in a busy parking lot 2Driving around the block 1Sitting in driver’s seat of car in driveway

65 Exposure hierarchy example – GAD SUDsTrigger 10Imagining spouse dying in car accident 9Reading article about cancer 8Imagining being fired from job 6Imagining son failing out of college 5Watching evening news 5Imagining being poor in retirement 4Reading article about bankruptcy 3Making a decision and not reversing it

66 Exposure hierarchy example – panic (interoceptive exposure) SUDsTrigger 10Running in place for 5 minutes (heart rate) 9Spinning in chair for 1 minute (dizziness) 7Straw breathing for 1 minute (not enough air) 6Over-breathing for 1 minute (hyperventilating) 5Walking up 1 flight of stairs (heart rate) 4Sitting in heated car for 3 minutes (heat) 3Standing up quickly (dizziness)

67 Tips when doing Exposure If in doubt, start low Conduct first exposure in session, if possible Research on therapist – assisted exposure in OCD Schedule adequate time Prep and orient, but don’t drag out Be aware of your style Confident Lots of praise esp. following exposure Coach Balance distraction/coping with focus on anxiety sensations Debrief afterwards to promote learning

68 Case Example Case example – Jayden Taught breathing and relaxation to entire family Started exposure with a low anxiety / high probability of success item (talking to a new person at our office), then extended to saying hello to baristas at coffee shops, then moved to saying hello to more people at school Gradually reduced reassurance seeking (cut by 50% as directed by child, with reward system). Worked with Mom to decrease overprotective behaviors and increase reinforcement for “brave” behaviors

69 Exposure, cont. Eventually did “silly” things (say hi in a foreign language, wear our shirts inside out downtown) Moved up hierarchy with parents gradually coaching more at home during exposures (e.g., laundry). Laundry: play reward game near laundry, then sitting on machine, then put clothes in laundry, then imagine being sucked in laundry with therapist

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71 What about traumatized kids / “normal” anxiety? Exposure to actual danger makes fear increase Exposure when situation is not dangerous will create decreased fear over time Consider adding safety cues to help lower anxiety level Talk it through, focus their attention externally, validate fear Add safety cues (reassurance, praise) If needed use distraction If anxiety can’t be tolerated – avoid and try to come back later Examples: Dentist / therapy dog Little Bear – “the clam”

72 Cognitive restructuring Clients learn to: Identity anxious thoughts Evaluate / challenge unhelpful or maladaptive thoughts Generate more balanced, accurate thoughts Coping thoughts must be believable and not just “positive thinking” Rehearsal Before anxious situations During anxious situations With practice, balanced thoughts come more automatically

73 Cognitive distortions in anxiety General Overestimating the likelihood of negative outcomes (“jumping to conclusions”) Catastrophizing (“worst case”)

74 Cognitive restructuring strategies Overestimating likelihood of negative outcomes: Identify all other possible outcomes to help determine the “real odds” of the feared outcome Catastrophizing: Generate a list of ways to cope with the worst case scenario

75 Cognitive restructuring Tread carefully and use validation Think developmentally Focus on helpfulness vs. accuracy If thoughts are resistant to change, back off and try again in another way or at another time

76 Cognitive restructuring example – separation anxiety Anxious thought: If my mom goes to work (at a college campus) she will get shot and killed. Cognitive restructuring: Evidence for: There have been several shootings at colleges recently Evidence against: There has never been a shooting at her campus; she has been to work hundreds of time and has always come home safely; she’s never been injured at work at all Coping thoughts: My mom will likely be okay at work. Her campus seems to be pretty safe.

77 Cognitive restructuring example – social anxiety Anxious thought: If I go to happy hour with my co- workers I won’t be able to come up with anything to say and I will look weird. Cognitive restructuring: Other possible outcomes: I am able to say something; I listen to others and just ask questions; I sit quietly and nobody notices; other people are quiet too. Real odds: Low. Coping with worst case: I could excuse myself to the bathroom and try to think of some things to talk about; I could think of ideas now before I go Coping thoughts: I will probably feel anxious but I can come up with at least 1 thing to say. I am not responsible for 100% of the conversation.

78 Cognitive restructuring example – panic Anxious thought: I feel lightheaded. I am going to pass out and make a scene. Cognitive restructuring: Other possible outcomes: I might not faint – I never have before; I feel lightheaded because I am anxious; the feeling will probably pass after a while. Real odds: Low. Coping with worst case: If I fainted other people around would probably help me; I would feel embarrassed but that would pass too – I could tell people that I have a medical condition Coping thoughts: I been lightheaded many times and have never fainted. I am not likely to faint but if I do other people will help me and I won’t feel embarrassed forever. You don’t die from fainting!

79 A caveat about OCD Cognitive restructuring can be problematic when treating OCD Core feature of OCD is a difficulty tolerating doubt and uncertainty Cognitive restructuring can play right into this difficulty and often does not “stick” due to lingering doubts Can use the strategies to focus on beliefs about thoughts vs. the content of the thoughts themselves

80 Cognitive restructuring example - OCD Anxious thought: If I have a bad thought something bad will happen to someone I love (example of thought action fusion) Cognitive restructuring: Socratic questioning about whether thoughts can impact events in the world Behavioral experiments to test this out – think about something falling from the sky and see if it does; think about a bug dying and see if it dies; work up to more difficult experiments about others being harmed by client’s thoughts

81 Response prevention Drawn from OCD treatment, but can be used broadly across anxiety disorders Response prevention can be thought of as the process of blocking any behaviors that are an attempt to neutralize anxiety (i.e., safety behaviors) Exposure less effective without RP, so its good to start before starting exposure if possible Often overlooked

82 Response prevention - steps Identify safety behaviors Develop a plan to reduce and eliminate them (this can be put on your exposure hierarchy) Goal is to work toward full response prevention whenever possible (i.e., elimination of all safety behaviors) For severe anxiety, esp. health anxiety or OCD, might have to start with response prevention

83 Response prevention example – driving phobia Safety behaviorResponse prevention plan Listen to talk radio as a distraction Lower volume of radio over time until radio is off altogether Carry full bottle of water in front seat of car whenever driving Switch to half empty bottle, then mostly empty bottle, and then no bottle Always drive in the slow lane on freeway Switch from slow lane to center lane and then to fast lane

84 Response prevention example – OCD (child) Ritual/compulsionResponse prevention plan 30 minute checking sequence before bed Decrease checking in steps, eliminating 1 or more components each week Change clothes after coming in from outside Decrease number of articles of clothing being changed in steps Confess to others when done something “bad” Decrease total number of confessions for the day in steps

85 Response prevention example – GAD Safety behaviorResponse prevention plan Call spouse repeatedly until reach him/her Call once and then do not call again if don’t reach him/her Check stock market updates online 15 times per day Check stock market information once per day Weigh pros and cons for lengthy period of time before making a minor decision Make minor decisions within specified time frame (e.g., a few minutes) and don’t undo them

86 Changing environmental contingencies/responses Assess carefully for: Reinforcement of anxious behaviors Lack of reinforcement for non-anxious behaviors Key people in client’s life should be involved in treatment during this module (if not already) Important to keep client in driver’s seat as much as possible

87 Changing the environment – child client (OCD) Problem: Anxious child with OCD whose parents participate in many of the child’s rituals to help decrease her anxiety Solution: Educate the parents about the role that their behaviors play in perpetuating the child’s anxiety Provide a clear rationale for why these behaviors need to change for the child to get better Teach parents how to reinforce non-anxious behaviors Provide a road map for when parents should stop participating in various rituals Assist parents as needed in tolerating their own anxiety about their child’s discomfort

88 Changing the environment – adult client (panic/agoraphobia) Problem: Anxious adult with panic disorder and agoraphobia who cannot go out in public without spouse (i.e., the spouse is a primary safety cue) Solution: Educate the spouse about the role that his/her behaviors play in perpetuating the client’s anxiety Provide a clear rationale for why these behaviors need to change for the client to get better Provide a road map for when the spouse should stop going various places with the client Teach spouse how to reinforce non-anxious behaviors Assist the couple in adjusting to new roles as the client becomes more independent

89 Relapse prevention Important to develop a relapse prevention plan with all clients prior to ending treatment Typical elements of this plan include: List of possible triggers that could lead to relapse of anxiety or other symptoms Plan for how to use skills learned in treatment to cope with these triggers Plan for how to identify and respond to new triggers and/or symptoms List of supports to enlist for help as needed Guidelines for when to return for booster sessions or a new course of treatment

90 Summary Modular treatment approaches use evidence based principles and interventions in a flexible way that allows for individualized treatment planning Approaching the treatment of anxiety in a modular way can highlight the commonalities among these disorders and how they are treated Focus is on doing what is likely to work for the unique symptom presentation of each client, within a framework of evidence-based practice If you know one CBT treatment for anxiety well, a lot of your knowledge will transfer to treating other anxiety disorders!


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