Therapy: Anxiety Management & Relaxation Psychological techniques for managing anxiety Frank McDonald Consultation-Liaison Psychologist The Townsville

Therapy: Anxiety Management & Relaxation Therapy: Anxiety Management & Relaxation

Psychological techniques for managing anxiety

Frank McDonaldConsultation-Liaison PsychologistThe Townsville HospitalQueensland Australia

Psychological techniques for managing anxiety

Frank McDonaldConsultation-Liaison PsychologistThe Townsville HospitalQueensland Australia

Edvard Munch, 1896 - ‘Anxiety’Edvard Munch, 1896 - ‘Anxiety’

http://www.edvard-munch.com/Paintings/anxiety/anxiety_3.jpg

OverviewOverview

• 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 • 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

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.

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 & ObjectiveAim & 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

• 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 mxGeneral 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

• 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

After Yerkes & Dodson 2After Yerkes & Dodson 2


• 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

• 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


• 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

• 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

Feelings & behaviour depend on interpretation of events


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

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

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


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

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 suchsolicitousness

Operant conditioning gone wrong! You positively & negatively

reinforce child’s anxiety with suchsolicitousness


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

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)

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 anxietyGeneral 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)?

• 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)?


• 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

• 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


• 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’

• 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’

Some psychological strategies for managing anxiety – an overview

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)

• 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

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RelaxSTOP

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The Principle of Exposure TherapyFear

Relax

Relax

Relax

Relax

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RelaxSTOP

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The Principle of Exposure Therapy

Some psychological strategies for managing anxiety – an overviewSome 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

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

Some psychological strategies for managing anxiety – an overviewSome 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)

• 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)

Some psychological strategies for managing anxiety – Class ExerciseSome 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?

• 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

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 techniquesPsychological 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)

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)



Psychological management PD+A• Regularising breathing rate – “slow & steady” 6 second cycle

technique• Graded exposure to feared situations. See next slide

Psychological management PD+A• Regularising breathing rate – “slow & steady” 6 second cycle

technique• Graded exposure to feared situations. See next slide



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)

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)



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

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



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)

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)



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

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!



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

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 Anxiety acquisition, extinction

& spontaneous recovery curves of classical conditioning

Anxiety acquisition, extinction & spontaneous recovery curves

of classical conditioning



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

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



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

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



Post-Traumatic Stress Disorder

Features 1. Exposure to extreme trauma e.g.

that threatens life2. Recurring images of the trauma 3. Distress triggered by similar

events; persistent hyperarousal 4. Avoidance of cues/reminders of

trauma

Post-Traumatic Stress Disorder

Features 1. Exposure to extreme trauma e.g.

that threatens life2. Recurring images of the trauma 3. Distress triggered by similar

events; persistent hyperarousal 4. Avoidance of cues/reminders of

trauma Bali bomb survivor 2002 Bali bomb survivor 2002



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

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



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

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



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)

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)



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 solutions Put down all ideas, even bad ones. List the solutions without evaluation at this stage. 1. ___________________________________2. _______________________________________3. _______________________________________4. _______________________________________5. _______________________________________6. _______________________________________

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 solutions Put down all ideas, even bad ones. List the solutions without evaluation at this stage. 1. ___________________________________2. _______________________________________3. _______________________________________4. _______________________________________5. _______________________________________6. _______________________________________



• 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 solution Choose the solution that can be carried out most easily to solve (or to begin to solve) the problem.

• 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 solution Choose the solution that can be carried out most easily to solve (or to begin to solve) the problem.



• 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. ___________________________________

• 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. ___________________________________



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? __________________________________________________

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? __________________________________________________

Collaborative ManagementCollaborative 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

• 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 anxietyEvidence 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)

• 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)


• 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

• 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


• 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

• 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


• 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-education2. verbal discussion techniques3. imagery modification4. attentional manipulations5. exposure to feared stimuli6. behavioural experiments, such

as manipulation of ‘safety behaviours’ (e.g. avoidances)

• 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-education2. verbal discussion techniques3. imagery modification4. attentional manipulations5. exposure to feared stimuli6. behavioural experiments, such

as manipulation of ‘safety behaviours’ (e.g. avoidances)


• 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

• 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

ResourcesResources

• 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.html

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 http://www.healthinsite.gov.au/topics/Causes_and_Treatments_of_Anxiety_Disorders

• 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.html

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 http://www.healthinsite.gov.au/topics/Causes_and_Treatments_of_Anxiety_Disorders

ResourcesResources

• 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 CRUfAD

http://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

• 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 CRUfAD

http://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

Optional Self-testOptional 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?

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?


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.

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.


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?

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?

Documents

Therapy: Anxiety Management & Relaxation Psychological techniques for managing anxiety Frank McDonald Consultation-Liaison Psychologist The Townsville