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REVIEW OF ANXIETY DISORDERS
Generalized anxiety disorder Panic disorder Phobias Obsessive compulsive disorder PTSD ASD
General schema model of anxiety disorder
Danger schemas formed
Critical incident Schemas activated Negative automatic thoughts Behavioral response Anxiety symptoms Cognitive biases
What‟s wrong with their information processing
Filtering (attending selectively to threatening stimuli) Discounting positives Undermining own ability to cope Access to threatening memories Projecting worst future scenarios
at least One month of anticipatory Anxiety. Of no reduction of distress by compulsions. avoidance Fear of social or performance situations Recurrent obsessions or compulsions (time/distress/impairmn) Cognitive themes Panic disorder Social phobia Obsessive compulsive Disorder Generalized anxiety Disorder Misinterpretation of anxious symptoms Concern about the consequences of panic Concern about appearing anxious before other. embarrassment in public Concern about consequences of obsessive thoughts/compulsive acts. Excessive and Concern about the uncontrollable worry uncontrollability and about many events (6m) danger of worrying . Disorder Key diagnostic feature Recurrent unexpected Panic attacks.
Panic disorder: case formulation interview Introduction: I‟m going to ask you about a recent typical panic attack so that we may begin to map out what happened. or an emotion (Q4)? 2. what was the very first thing that you noticed that indicated that you might panic? Was it a thought (Q3). a sensation (Q2).When you noticed that sensation what thought went through your mind? 3. When you noticed the thought how did that make you feel emotionally? . When was your most recent panic attack? 1. Thinking about just before you panicked.
Did you do anything to lower anxiety? What was that? 9. What happened to your anxiety when you thought that? 8. Since you have developed panic do you focus attention on your body/thoughts? .4. When you noticed that emotion what sensations did you have? 5. How much did you believe (insert catastrophic misinterpretation) those thoughts at that time? 7. When you had those sensations what thought went through your mind? 6.
Trigger Response to trigger.1.behaviour .thought Response to trigger-emotion 7.Panic Belief that I am dying Response to trigger Sensory ampfcn Safety behaviour/counters Anticipatory anxiety .
Panic disorder: treatment Psycho education Exposure to internal cues (spinning in the chair. swaying head from side to side) Cognitive restructuring – decatastrophizaton Graded exposure to feared events (or usual activities that were being avoided) Practice in as many contexts as possible Talk about safety behaviours/ counters . hyperventilating.
Panic disorder: treatment Behavioural (or largely behavioural) techniques Relaxation Imagery Breathing exercise Others .
Cognitive restructuring .
Goals of a patient with panic disorder (exposure) "To travel alone by train to the city and return at peak hour" "To shop alone in the local supermarket and do the weekly shopping" "To go to the movies at night with friends and sit in the middle of the row" .
peak hour Travelling one stop in an underground train. quiet time of day Travelling two stops in an over-ground train. peak hour Travelling five stops in an underground train. quiet time of day Travelling two stops in an underground train. peak hour .Break up first goal into small. quiet time of day Travelling five stops in an underground train. easy to do steps Travelling two stops in an over-ground train.
You may use your slow breathing exercise to reduce your breathing rate if it is higher than it should be. For example.Plan and prepare before exposure Use the progressive muscle relaxation.. Monitor your breathing rate at regular intervals e.g. once every 5-10 minutes. Give yourself plenty of time. mentally rehearse some coping statements to say to yourself as the doors close. if you are traveling by train. Mentally rehearse your activity. as more people get on and so on. . Perform all activities in a slow and relaxed manner. isometric or slow breathing exercises if possible before you go out.
staying for two hours in a shopping centre is better for you than going here for a total of two hours on four occasions. Congratulate and reward yourself for attempting or completing exposure tasks . The longer you remain in a situation the calmer you will become and the faster you will overcome your fears e. If you do not do this you may interpret it as a failure and lose confidence.face it. let it fade away and then either move on or return. Do not leave a situation until you feel yourself to be calming down.g. accept it. Never leave the situation out of fear ..
or even distraction techniques in the treatment of panic disorder.Doubts about behavioral techniques or medication in treatment of panic disorder Questions are being raised about use of medications. we must repeat CBT sessions once these are discontinued. imagery. relaxation. (these may be used by patients as counters/safety behaviours/ escape behaviours) If we have to use the above techniques. .
Social phobia .
Graded exposure Social skill training Assertive training Not for all .
two. Fie. my lord. why then „tis time to do‟t. Hell is murky.Obsessive compulsive disorder “Out. look not so pale…” . put on your nightgown. damned spot! Out.Wash your hands. I say! One. fie! …… Yet who would have thought the old man to have had so much blood in him? ….
Won‟t be alone with baby.OCD: common obsessions and compulsions Contamination Physical violence to self and others Images of loved ones dead Impulse to shout out an obscenity Wash. check body for symptoms of disease. hides knives. Counter imagination of same people alive Avoids social situations. asks others whether behaviour was acceptable in particular situation. Ring doctor. seeks reassurance. .
OCD: case formulation interview Introduction: I am going to ask you about the last time you were distressed by an obsessional thought and you felt compelled to respond to it. 1. What was the thought/image/impulse that triggered you? 2. When you had that thought how did you feel emotionally (eg anxious /scared/ depressed)? .
Did you do anything to stop from happening? Did you do anything to stop yourself doubting? Did you try to prevent feeling anxious? (what did you do?) 5. Do you believe that you must behave in certain ways in order to remain safe and stop bad things from happening? . Do you believe these thoughts mean something? What is the worst they could mean? How much did you believe that at the time? 4.3.
1. Trigger – thought/image/impulse What does the trigger personally mean to the patient? Amount of distress it caused Did he try to fight back rationally Did he give in to compulsive acts? .
Treatment of OCD: rationale of ERP With exposure and ritual completion .
With exposure and response prevention .
*ERP Exposure with positive self talk No bland reassurance Ask patient to treat this as a behaviour experiment. Usually lasts two hours. Modelling .
Principles of ERP Limits will be set on your ritualized behaviour Graded exposure You will not use counters Family members will not be enlisted to carry out your rituals. .
More cognitively oriented strategies (besides ERP) Over importance of thoughts Over estimation of threat/all or nothing thinking Thought .action fusion Difficulty handling doubt and uncertainty Over responsibility Emotional reasoning .
Ask yourself Where is the evidence? Even if internal self talk appears logical and accurate. . Do a cost benefit analysis. are the feared consequences really as awful or catastrophic as the OCD is trying to make them out to be? Reduce all or nothing thinking.
The same questions have been raised about thought stopping also. .But beware… Is the CT turning into one big repetitive self reassurance ritual? Then throw the CT out of the window. Use of CT strategies during flooding style ERP tasks can dilute the intensity of the exposure task and thereby reduce potential for habituation gains. though it is still used effectively by many therapists. Is your self talk becoming another obsession? Then abandon it.
GAD: Psycho education .
Imaginary exposure .
Relaxation therapy .
THANK YOU .
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