Cognitive Behaviour

Therapy for Anxiety

Jodie Paget BSc Hons, PG Cert, PG Dip

Associate Tutor CBT Skills

CBT is…

An action orientated psychotherapy that

teaches individuals to identify, challenge,

and replace their self-defeating thoughts and

beliefs with healthier thoughts that promote

emotional well-being and goal achievement.

Men are disturbed not by things, but by

the view which they take of them -

Epictetus

CBT Model

The basic CBT model proposes that every

experience we have has specific thoughts

(beliefs), emotions, physiological responses

and behaviour associated with it.

You have been told you are losing your job

Scenario

How might you feel?

Angry, Anxious, Depressed…Happy?

What would you need to think (and believe)

about losing your job to feel each of the

above?

• How we feel emotionally gives us a very good insight

into what we are thinking and the ‘health’ of our thoughts.

• So feeling extreme anxiety accompanied by physical

discomfort (headaches, nausea, IBS etc…) would

suggest some ‘unhealthy’ thinking is occurring.

• Healthy beliefs result in healthy emotional and

behavioural responses.

What is Anxiety? CBT defines anxiety as an emotion, more specifically an unhealthy

emotion. Unhealthy emotions always result from unhealthy thinking and

most often produce maldaptive behaviour responses.

Thought Process

Overestimation of threat

Underestimation of ability to cope

Creates even more negative threat in ones mind

Has task irrelevant thoughts

Behaviours

Withdraw from threat (Physically or mentally)

To ward off the threat (by superstitious behaviour)

To seek reassurance

Healthy Concern rather than Anxiety

Overestimation of threat/danger

Anxiety= Underestimation of coping + rescue factors

Concern is viewed as a healthy emotion in that it is always associated with the

following:

Thoughts

Views threats realistically

Realistic appraisal of coping ability

Does not create an even more negative threat in ones mind

Has more task relevant thoughts than in anxiety

Behaviours

To face up to threat

To deal with threat constructively

Anxiety Disorders

There are many types of anxiety disorders – we are covering:

Panic Disorder

Social Anxiety Disorder

Health Anxiety

Safety Behaviour A behaviour engaged in that ‘prevents’ catastrophe from occurring

Panic Disorder

• A panic attack is an abrupt surge of

intense fear that reaches a peak within

minutes, during which time 4 or more of a

list of 13 symptoms occur.

• The attack appears to come ‘out of the

blue’

• 2%-3% in adults and adolescents

• Females out number males by 2:1

Panic Attack Criteria

• 1. Palpitations, pounding heart, or accelerated heart rate.

• 2. Sweating.

• 3. Trembling or shaking.

• 4. Sensations of shortness of breath or smothering.

• 5. Feelings of choking.

• 6. Chest pain or discomfort.

• 7. Nausea or abdominal distress.

• 8. Feeling dizzy, unsteady, light-headed, or faint.

• 9. Chills or heat sensations.

• 10. Paresthesias (numbness or tingling sensations).

• 11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).

• 12. Fear of losing control or "going crazy."

• 13. Fear of dying.

The Cognitive Model of Panic Internal/External Trigger

Palpitation, shortness of breath

Perceived Threat

I can’t breathe, I might faint

ANXIETY

(Panic)

Physical/Cognitive Symptoms

My chest is getting tighter

My heart is racing – there is

something wrong with it

Pounding chest, dizziness, tunnel

vision, dry mouth

Catastrophic Misinterpretation

I’m going to die

I’m going to pass out and nobody

will help

Avoidance and Safety Behaviours

(What you did that prevented the catastrophe)

Left the situation

Never go out alone

Take unnecessary medication

Avoid exercising

Working with Panic Disorder

• Psychoeducation – physiology of anxiety, triggers, and the maintenance cycle

• Theory A vs. Theory B

• Panic Diaries

• Identifying (and dropping) safety behaviours

• Induction of anxiety symptoms

• Fear Hierarchy - Behaviour Experiments

• Relapse prevention

Social Anxiety Disorder

• Intense, fear of social situations in which the individual may be scrutinized by others (FNE).

• Concerned that he or she will be judged as anxious, weak, crazy, stupid, boring, intimidating, dirty, or unlikable etc.

• The individual fears that they will act or appear in a certain way or show anxiety symptoms (blushing, trembling, sweating etc) that will be negatively evaluated by others.

• The individual will often avoid the feared social situations or endure them with intense fear.

• Avoidance can be extensive (e.g., not going to parties, refusing school) or subtle (e.g., over preparing a speech, diverting attention to others, limiting eye contact).

The Cognitive Model of Social Anxiety Disorder Social Situation

Group Discussion

Activates Assumptions

I must not show signs of anxiety

I must appear competent

Perceived Social Danger

(Negative Automatic thoughts)

They think I am stupid

They think I’m anxious

Processing of Self

as Social Object

Self Conscious,

image as bright red,

is aware of own voice Safety Behaviours

Not participate

Sit at the back

Not make eye contact

Somatic and Cognitive

Symptoms

Trembling, racing heart, dry throat,

difficulty concentrating

Co

nta

min

ation

How CBT works with Social Anxiety Disorder

• Psychoeducation – The model, triggers

• Eliciting thoughts, and assumptions

• Eliciting safety behaviours and anxiety symptoms

• Disputing assumptions and challenging negative automatic thoughts (thinking errors)

• Behaviour experiments to test predictions

• Modifying self-processing in the moment (attentional training)

• Managing anticipatory anxiety (cognitive restructuring, distraction)

• Managing the ‘post mortem’ (Assess the pros and cons of the post mortem, it’s

distorted nature then finally banning it)

Health Anxiety (Illness Anxiety Disorder)

formerly Hypochondriasis

• Preoccupation with having or getting a serious medical illness

• Checkups often do not detect any medical problems however despite this the individual's anxiety comes from not the illness itself but rather the meaning and/or significance of the illness.

• If a symptom is present, it is often a normal sensation (e.g. dizziness), or a bodily discomfort not generally considered indicative of disease (e.g., belching).

• If a diagnosable condition is present, the anxiety and preoccupation are excessive and disproportionate to the severity of the condition

• Two Types of behaviour:

• Care Seeking and Care avoidant

The Cognitive Model of Health Anxiety

Negative Automatic Thoughts

There is something terribly wrong with me, I must know

what’s wrong, I can’t bear not knowing

Anxiety Behaviour

Reassurance seeking

Visiting the doctor

Checking the internet

Scanning for symptoms

Avoidance

Cognitive

Focusing on symptoms

Discounting medical feedback

Overemphasising the

significance of symptoms

Physiological Changes

Increased arousal

Trigger

Death of a friend/family member

How CBT works with Health Anxiety

• Explore evidence for disease fears

• Assess avoidance and safety behaviours

• Managing selective attention

• Explore alternative evidence for disease and develop alternative

explanation for symptoms (Theory A and Theory B)

• Behaviour experiments to challenge misinterpretations (drop safety

behaviours, avoidance, checking etc)

• Fear Hierarchy (exposure)

• Explore the role of reassurance seeking – eventually dropping it

• Introduce rational responding to thoughts

Summary What is the danger? Appraise this realistically

How will I cope with it, what are my rescue factors?

– How have I coped with similar situations?

– What are my transferable strengths?

– Engage in a problem solving mindset rather that circular worry

– Dispute your anxiety generating beliefs and develop balanced coping

beliefs, practice behaving in accordance with these beliefs

If you can behave productively DO IT!

- Problem solving, generate three solutions, assess them accordingly

- if this isn’t possible use distraction (an activity that heavily engages your

mind or your body

Develop a list of distraction methods/activities that work for you

If symptoms persist practice tolerating them, challenge your belief that

they are UNBEARABLE

Questions