Anxiety

Disorders
The CBT Perspective
CBT Formulation of Anxiety
• Underlying beliefs and assumptions concerning danger (danger
schemas)
• Such schemas shape interpretations of experience and when
activated by precipitating events introduce distortions in processing
that are manifest as negative automatic thoughts.
• Cognitive distortions and behavioral responses contribute to the
maintenance of disorder since individuals are unable to reality-test
their beliefs effectively.
General
overview*
Anxiety’s cycle
Positive Beliefs About Worries

Worrying:
• Is useful for finding solutions to problems
• Is motivating – helps get things done
• Is protective from negative emotions
• Can prevent negative outcomes
• Is a positive personality trait
(Francis & Dugas, 2004)
Negative Problem Orientation
• Problems are threat to well-being
• Doubt about problem-solving ability
• Pessimism about problem solving outcome
• Negative problem orientation is more specific to worry
than depression in student samples, and is differentiated
from neuroticism
(Robichaud & Dugas, 2005, BRAT)
All current models tend to underscore
avoidance of internal experiences
• Cognitive avoidance
• Emotional avoidance
• Intolerance of uncertainty
• Negative cognitive reactions to emotions
Treatment Elements
Borkovec

1. Awareness and self-monitoring

2. Relaxation
3. Cognitive therapy
4. Imagery rehearsal of coping strategies

(see Borkovec, 2006 for review)

Relaxation Strategies (reviewed
later)
• Progressive Relaxation (PR; e.g., Bernstein & Borkovec,
1973)

• Applied Relaxation (AR;O¨ st, 1987).

• AR does include exposure elements
Mechanism of Relaxation Training
(Ost, 1992)

• Reduces general tension and anxiety (and link

stressor/panic)
• Enhances awareness about how anxiety works, de-
mystifying and diminishing its impact
• Enhances self-efficacy : individuals feel equipped to
cope with anxiety
The “Words” of Worry
• Non-specific and hard to dispute
• It will be horrible
• It will be a disaster
• Downward Arrow Techniques to clarify worries and put
them in a form appropriate for cognitive-restructuring
Downward arrow technique
Cognitive Restructuring
• Self monitoring
• Logical analysis
• Probability overestimations
• Overestimations of the degree of catastrophe
• Ability to cope
 Problem-oriented-focus
• Not all anxiety disorders are alike, not all CBT treatments are the same
• First step: understand the particular ABC’s (including emotions and physical
symptoms*)
• Use assessment tools
• A note on physical symptoms: Hyperthyroidism, mitral valve prolapse, cardiac
arrhythmias, tumors, vestibule disturbances, and a range of other conditions can be
the source of panic-like sensations and other anxiety-like symptoms such as dizziness,
cardiac symptoms, blushing, loss of balance, and so on.
• An anxiety disorder is not diagnosed if the symptoms can be explained by medical
conditions, or if the symptoms occur solely as a result of dependence on or
withdrawal from substances such as caffeine or alcohol.
• Accurate and thorough assessment is required in order to formulate and plan an
appropriate intervention.
• Panic attacks
• the persistence of panic attacks in the absence
of biological or chemical causes is associated
with catastrophic misinterpretations.
• Themes: dying, suffocating, having a heart
attack or seizure, and fainting or collapsing*,
losing one’s mind.
• Then: The non-occurrence of catastrophe is
attributed to use of ‘safety behaviors'
(Salkovskis 1991), thereby preventing belief
change.
Formulati
on and
Q’s

See video example or

book p. 59
Social Phobia
• Vs Timid: what is the difference?
• DEVELOPMENT:
• embarrassment reflects “exposure of the self when the individual is the object of attention
from others” rather than negative evaluation in performance situations, Lewis and Ramsay
(2002, p. 1034) refer to it as “exposure embarrassment.” “Evaluation embarrassment,” which
is evident in the context of perceived failure or negative feedback, appears to emerge later in
development, around the age of 3 years (Lewis, Alessandri, & Sullivan, 1992), and to be
associated with elevated cortisol (Lewis & Ramsay, 2002). …self- awareness and in capacity to
evaluate one’s performance against external standards
• Kids: shy behavior and social adjustment difficulties, including perceived poorer
friendship quality, trait anxiety, and lower ratings of global self-worth, were
significantly related, particularly in the older children in the sample.
• Adlcs: pertained to inter- personally relevant issues such as peer rejection, neglect,
or scapegoating; personal appearance; or concern about others’ feelings. When
performance-related concerns, which often also involve social-evaluative
component
• Gender: for girls, the most consistently prevalent worries were about
school performance (40.1% and 45.6%) and weight (29% and 38.3%),
whereas for boys, the most prevalent concerns were school
performance (39.1% and 35.6%) and unemployment (35.6% and
25%).
• Cognitions:
• The ability to shift attention away from negative internal states may be
especially critical to the management and prevention of social anxiety.
• Ruminative or emotion- focused coping strategies, for example, which
involve sustained focus on internal discomfort, have been shown to relate to
elevated levels of anxiety (Blankstein, Flett, & Watson, 1992; Rose, 2002). ..
findings suggest that poor attentional control during negative emotional
states may amplify later anxiety and anxious behavior.
Concurrent
• “common to virtually all of the anxiety disorders is a persistent
tendency to experience any of a wide range of anxious symptoms,
which can be somatic (e.g., racing heart, sweating, nausea,
trembling), cognitive (e.g., worry, fear), or behavioral (e.g.,
avoidance, tearfulness). These symptoms may occur discretely or in
clusters; when four or more somatic or cognitive symptoms suddenly
co-occur and rapidly peak in the context of intense fear, they
constitute a panic attack.
• “Safety or Maintenance behaviors” (or negative reinforcement)
• (a) the non-occurrence of social catastrophe is attributed to use of the
behavior and so negative beliefs about failed performance or showing signs of
anxiety persist;
• (b) some safety behaviors intensify or prolong unwanted symptoms (e.g.,
wearing extra clothing increases sweating);
• (c) some safety behaviors increase self-focused attention the problem here is
that self-attention amplifies awareness of symptoms, contributes to self-
consciousness, and interferes with the task concentration required for
effective social performance;
• (d) safety behaviors can contaminate the social situation by making the
person appear withdrawn, disinterested, or unfriendly.
• Fomulation
and Q’s
• Example
Also watch video
interview,
 Generalized Anxiety
Worry episodes have a trigger, often in the form of a
negative ‘What if . . .?’ question.
• This activates positive metacognitive beliefs about the
use of worrying as a coping strategy. Positive beliefs
include themes such as: ‘Worrying means I’ll be
prepared,’ ‘If I worry I won’t be taken by surprise,’ and ‘If
I worry I’ll be able to cope.’
Metacognitive beliefs:
(a) beliefs about the uncontrollability of worry;
(b) (b) beliefs about the dangers of worrying for physical,
psychological, and social functioning.
Examples:
‘Worrying is uncontrollable,’ ‘Worrying will damage my
body and cause a heart attack,’ ‘If I worry I could become
schizophrenic or lose my mind,’ and ‘When people discover
I worry they will reject me.’
Worry-maintenance
• Behaviors such as avoidance of situations that may trigger
worrying, seeking reassurance, and information search (such as
surfing the internet) are used to try and stop worrying. However,
these strategies have counterproductive effects.
• Suppression of this kind is not consistently effective and may backfire,
increasing intrusions and adding to fears of uncontrollability.
New Directions

• Attentional training
• Mindfulness/emotional tolerance training
• Interoceptive exposure
• Integrative treatment
Common CBT
techniques
For anxiety
 Progressive muscle relaxation
• What is it?
• What is the goal?
• Develop the ability to train one’s body to relax voluntarily (learn it, then make it
conditioned, automatic)
• What is theory behind it?
• The physical behaviors associated with certain cognitions and contingencies associated
with anxiety require modification
• These physical reactions have been previously conditioned, and are now maintaining the
cognitions through a “self-fulfilling prophecy” cycle
• How is it used?
• Modifying contingencies
• ABC conditioned response learning
“SUDS” (Subjective Units of
Distress)
• Personal measure of distress
• Allow for a hierarchy of stress-anxiety related to certain stimuli
• Allow a patient to view growth and improvement
• Allow empathy and understanding (for therapist and patient)
• Enable CBT to conceptualize and formulate a progression
• Successive approximations
Exposure therapy
• Theory:
• The body can only react so much to a stimulus
• Pro’s and con’s:
• Allow for a real-world intervention vs. the possibility of re-traumatization or
over-exposure (SUDS can help)
• Can be aided y visualization and imagery techniques
 ERP (Exposure Response
Prevention)
• Exposure based, often used in cases of OCD
• Responses are prevented when faced with the
compulsion or anxiety-evoking situation
• Uses SUDS, may use visualization, most commonly and effective
are in vivo situations
• Is aided by reassurance and relaxation or acceptance-based
techniques
• Results in habituation and the decrease of maintenance-
behaviors based on cognitive distortions and automatic
thoughts as: catastrophizing, magical thinking, etc.
• Extinction Burst
• Video
Visual imagery
• Theory:
• Cognitions often involve visualizations of objects, places, persons or events
that are parallel with emotional states
• When feeling anger you imagine other’s expressions, or past events, or maybe even red,
and also “negative self-talk”
• When happy you imagine past and futures happy events, or a favorite place
• Guided visualization can help a patient reverse such cycles
• Visualizations can be modeled and modified, and as a result, so can some of the affective
experiences associated with them
• For anxiety, for social performance, for PTSD, for pain
Mindfulness –

• Curious attention to the present moment, in an

open, nonjudgmental, and accepting manner

• (Bishop et al., 2004; Germer, 2005; Kabat-Zinn, 1994)

Why Mindfulness?
• Hayes and Feldman, 2004
• Mindfulness training may enhance emotional regulation by
addressing the patterns of over-engagement (e.g., rumination)
and under-engagement (avoidance) that characterizes the
disorder.
• Target is a healthy level of engagement that “allows clarity and
functional use of emotional responses”
• Roemer et al, 2009
• Non-clinical symptoms and clinical GAD status linked to lower
mindfulness
DBT and mindfulness
• Developed by Linehan
• Initially for the treatment of suicidal behavior, but then for BPD
(anxiety, depression, impulsivity, interpersonal conflict)
• Dialectical:
• Based on change AND acceptance
• Incorporating an acceptance based technique and attitude: mindfulness
Therapists’ Working Assumptions
about the Client
1) The client wants to change, and despite appearances,
is trying his/her best as a particular time.

2) His/Her behavior pattern is understandable given

his/her background and present circumstances.

3) In spite of this, he/she needs to try harder if things are

to improve.

4) Clients can not fail at DBT.

Therapists’ Dialectical Style
• Reciprocal communication vs. Irreverent communication.
– Accepting of the client as he/she is, but encouraging change.

– Centered and firm, yet flexible when the circumstances require it.

– Nurturing, but benevolently demanding.

 Skills (or components of DBT)
• Emotion regulation training teaches a range of behavioral and cognitive
strategies for reducing unwanted emotional responses as well as impulsive
dysfunctional behaviors that occur in the context of intense emotions by
teaching clients how to identify and describe emotions,
• Distress tolerance training teaches a number of impulse control and self-
soothing techniques
• Interpersonal effectiveness teaches a variety of assertiveness skills to achieve
one’s objective while maintaining relationships and one’s self- respect.
• Mindfulness skills include focusing attention on observing oneself or one’s
immediate context, describing observations, participating (spontaneously),
assuming a non- judgmental stance, focusing awareness, and developing
effectiveness (focusing on what works).
 Foundations of Practice
Kabat-Zinn (1990) Seven Core attitudes
• Non-judging
• Patience
• Beginners Mind
• Trust
• Non-Striving
• Acceptance
• Letting go/be or non-attachment
Mindfulness Meditation

Mindfulness meditation is
NOT:
‑ Positive thinking

‑ Just another relaxation technique

‑ Going into a trance

-Trying to blank your mind

CBT technology!
• Apps
• Videos
• Combination of mindfulness, muscle relaxation and diaphragmatic
breathing
• Headspace
• Mindfulness
• Diaphragmatic breathing
• Relxation vislualization
• Habituation (flights)
• VR
Homework
• Look for Anxiety-related documentaries/short films
• Describe the situation of the sufferer
• What is their personal experience?
• How do you understand it from a CBT perpective?
• Make a quick formulation
• Suggest some techniques! Why those?
 Today’s activity
• With a partner:
• Review your answers to Anxiety Scales
• Define or operationalize the symptom (Trigger-
Thoughts/beliefs-response to event or behavior)
• Think of a technique that could be useful
• Indicate why you think it could be useful.