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CBT - Anxiety
Denise Hashempour
Pause for thought
• What is worry?
A prediction that something bad is going to happen
or something has gone wrong and a person
ruminates about it.
• What is anxiety ?
The experience itself
• What is fear ?
Anticipation of something happening in the future,
with a clear conviction.
DSM IV Anxiety Disorders
Acute Stress Disorder
Social Phobia
Generalised Anxiety Disorder
Panic Attack
Specific phobias
Obsessive Compulsive Disorder
Post Traumatic Stress Disorder
Anxiety Disorder due to general medical condition
Agoraphobia without history of Panic Disorder
Panic Disorder without Agoraphobia and Panic Disorder with
• Anxiety Disorder not otherwise specified
• All of the disorders have a criteria of severity.
The anxiety disorder has to be severe enough
to be classed as interfering in an individual’s
life. This includes work commitments, social
activities, educational commitments and any
other activities they take part in.
Wells and Butler’s Model
A metacognitive model of GAD, emphasises the
role of worrying. Wells and Butler (1997)
indicate that GAD patient’s overestimate the
likelihood of negative events, rate the cost of
threatening events as very high. They proposed
that GAD patient’s have both positive and
negative belief’s about worrying. Worry about
worrying, but giving up worrying may expose
them to unforeseen danger.
Type 1 and Type 2 Worry
Concern or vigilance about external or internal events e.g health
Worry or “metaworry” negative appraisal of one’s own cognition
processes e.g. Worrying will make me crazy
Therapeutic model looks at identifiying patient’s beliefs about the
costs and benefits of worrying , the recognition of productive worrying
experiment’s in ‘letting go’ or postponing worry, challenging avoidance
of activities or thoughts about which the patient worries and
constructing positive outcomes in imagery.
Wells, A, & Butler, G. (1997) in Leahy, R, & Holland, S. (2000) Treatment
Plans and Interventions for Depression and Anxiety Disorders (ed.) The
Guildford Press
DSM-IV diagnostic criteria for 300.02 Generalised
Anxiety Disorder
• Excessive anxiety and worry (apprehensive expectation),
occurring more days than not for at least 6 months, about a
number of events or activities (such as work or school
• The person finds it difficult to control the worry.
• The anxiety and worry are associated with three (or more)
of the following six symptoms (with at least some
symptoms present for more days than not for the past 6
months). Note: Only one item is required in children.
• Restlessness or feeling keyed up or on edge.
• Being easily fatigued
• Difficulty concentrating or mind going blank
• Irritability
Muscle tension
Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
The focus of the anxiety and worry is not confined to features of an Axis I disorder,
e.g., the anxiety or worry is not about having a Panic Attack (as in Panic Disorder),
being embarrassed in public (as in Social Phobia), being contaminated (as in
Obsessive-Compulsive Disorder) being away from home or close relatives (as in
Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), or having a
serious illness (as in Hypochondriasis), and the anxiety and worry do not occur
exclusively during Posttraumatic Stress Disorder.
The anxiety, worry, or physical symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
The disturbance is not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism)
and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a
Pervasive Developmental Disorder.
• GAD correlates highly with depression and
hopelessness, trying to solve a future that does
not exist
• Non GAD’s will respond with appropriate
cardiovascular responses when shown either
happy or sad people. People with GAD no
• Very frequently Co morbid disorder
• Worry inhibits emotional processing, so worry
before, during and after exposure.
NICE Guidelines
/54074/54074.pdf Guide to self help
• 1.2.14
• Psychoeducational groups for people with GAD should:
be based on CBT principles, have an interactive
design and encourage observational learning
include presentations and self-help manuals
be conducted by trained practitioners
have a ratio of one therapist to about 12
usually consist of six weekly sessions, each lasting
2 hours. [new 2011]
• 1.2.15
• Practitioners providing guided self-help and/or
psychoeducational groups should:
receive regular high-quality supervision
use routine outcome measures and ensure
that the person with GAD is involved in
reviewing the efficacy of the treatment. [new
Understanding Anxiety
• Most people who are anxious are very aware of
there physical symptoms. – Misinterpretation of
bodily sensations.
• All the physical, behavioral and thinking changes
experiencend are part of our anxiety responses
“Fight or Flight” or “Freeze”
• The thoughts that accompany anxiety are
different to those that characterize depression.
Anxiety is accompanied by the perception that
we are in DANGER or that we are THREATENED or
Anxiety Profile
• Sweaty Palms
• Muscle Tension
• Racing heart
• Flushed cheeks
• Light-headedness
Anxiety Profile
Physical Reactions
Sweaty palms
Muscle tension
Racing heart
Flushed cheeks
Light headedness
Underestimation of ability to cope
Underestimation of help available
Overestimation of danger
Worries and Catastrophic thoughts
• Avoiding situations where anxiety may occur
• Leaving situations when anxiety begins to
• Trying to do things perfectly or trying to
control events to prevent danger
What if
• What if the airplane explodes
• What if I crash my car
• What if people laugh
• What if I stumble over my words
• What if people think I’m stupid
Future orientated/predict danger or
catastrophe/something terrible is going to happen.
What if it’s not about me? – The best way to
reduce a non-adaptive behavior is to strengthen it’s
adaptive opposite
Nature of Worry
• Cognitive : It’s in the head thoughts,
memories, predictions, images
• Analysis: It’s about Emotional Suppression
• Interpersonal : I am not having my needs met
by other people (I’m confused because this
should be working)
• Behaviour : I need to change the way I
respond to the word
• What strategy do you use to manage your
own anxiety ?
Cognitive Restructuring
Anxiety can be reduced either by decreasing
perception of danger or increasing confidence in
ability to cope with threat.
Cognitive restructuring will involve evaluating
your estimation of danger by identifiying
thoughts associated with anxiety and improving
awareness of coping options.
Relaxation Training
Focusing on physical and mental relaxation can
alleviate anxiety as it is difficult for the body to
be both relaxed and anxious .
Relaxation can reduce the frequency and
severity of the anxiety experienced.
Progressive Muscle relaxation
• Nice Guidelines 2011
A technique in which the major muscle groups
in the body are alternately tensed and relaxed.
Controlled Breathing
• Breathing into a count of 4 and out to a count
of 4 for 4 minutes.
Psycho Education
• Explain the basic cognitive model of anxiety
• Inform effectiveness of treatment of CBT for
treatment of anxiety
• Collaboration client will have a central role in
securing change
• Normalising anxiety as a common and normal
• Understanding the fight and flight response
Psycho Education cont
• Highlighting the link between cognitions and
anxious bodily signals
• Raising awareness of cognitive distortions and
biases associated with anxiety
• Specifying the effects on behaviours in terms
of avoidance, loss of motivation and anxious
• Safe place imagery
• Conveyor belt metaphor
• When using case formulation we often neglect
the role of specific, problematic images, unless
we are already expecting them to be part of the
formulation e.g. in Social phobia or PTSD. In
social phobia intrusive negative images of self
lead to current distress and related safety
behaviours. Hackman et al 2011
• This may help reduce the frequency and
severity of anxiety.
Behaviourists would argue that this could be
interpreted as avoidance
Overcoming Avoidance
• A hierarchy of feared situations
• In Vivo exposure
Explain that with repeated exposures anxiety gradually decreases
Monitor both the level of Subjective units of discomfort (SUDS) and duration
(minutes) of anxiety to help clients see the changes within sessions and
across sessions
Subjective unit of discomfort (SUDS)
Rating record at least one situation for each rating
0 Patient is totally relaxed, on the verge of sleep.
25 mild anxiety, Does not interfere with performance
50 Uncomfortable concentration is affected
75 Increasingly uncomfortable. Patient becomes preoccupied with symptoms.
Thinks about escaping the situation.
100 Highest anxiety the patient has ever experienced
Behavioural Exposure Hierarchy
10 Worst Fear…………………………….
01 …Least fear……………………………….
The Rationale Response
Having identified a ‘Hot Thought’
List facts that do and do not support the ‘hot
Based on the evidence for and against
A summary of all the evidence
If my ‘hot’ thought is true what is the BEST,
Medication - BNF
• Nice Guidelines recommends use of
medication for short periods only to treat
Panic example
( Physical sensations)
“Something is terribly wrong with me”
“This is serious I am having a heart attack”
Go to emergency
Check for signs and
Behavioural Model
Threat or danger !
Increased anxiety
Escape or Avoidance
Negative reinforcement
Questions ?