Therapy: Anxiety Management

1
Therapy Anxiety Management Relaxation

• Psychological techniques
• for managing anxiety
• Frank McDonald
• Consultation-Liaison Psychologist
• The Townsville Hospital
• Queensland
• Australia

Edvard Munch, 1896 - Anxiety
2
Overview

• 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

3
Aim Objective

• Aim
• To briefly survey some psychological strategies
  for mx of anxiety(Some easily acquired or a
  natural part of medical roles that youll develop
  soon, if havent already. Others need further
  training or referring on)
• Objective
• Students will be more aware of psychological
  methods of managing common anxiety presentations

4
General 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
•  

5
General comments on psychological mx

• 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

6
General comments on psychological mx

• 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

7
General comments on psychological mx

• 2. Behaviour Therapy
• Behaviourists To feel differently, act
  differently. Change behaviour or manipulate
  environment.
• - They apply principles of 3 main theories of
  learning
• Classical conditioning (Ivan Pavlov) learning
  by association
• Relaxation exposure (systematic
  desensitisation, flooding response prevention)
  are behavioural anxiety mx methods based on
  classical conditioning

8
General comments on psychological mx

• 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

9
General comments on psychological mx

• 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

10
General 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)?

11
General considerations in medically managing
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

12
General considerations in medically managing
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

13
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)

14
Some psychological strategies for managing
anxiety an overview

• Graded exposure (contd)
• 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. doesnt
  have to be perfectly relaxed manageable is
  fine
• Can be therapist-assisted or self-directed

15
Some 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, owise 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)

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Some 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?

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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

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Common Anxiety Disorders When how to apply
techniques

• Psychological management PDA
• 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)

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Common Anxiety Disorders When how to apply
techniques

• Psychological management PDA
• Regularising breathing rate slow steady 6
  second cycle technique
• Graded exposure to feared situations. See next
  slide

20
Common Anxiety Disorders When how to apply
techniques

• 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)

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Common Anxiety Disorders When how to apply
techniques

• 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

22
Common Anxiety Disorders When how to apply
techniques

• 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-stressing7)

23
Common Anxiety Disorders When how to apply
techniques

• 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 isnt good
enough!
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Common Anxiety Disorders When how to apply
techniques

• 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

25
Common Anxiety Disorders When how to apply
techniques

• 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

26
Common Anxiety Disorders When how to apply
techniques

• 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

27
Common Anxiety Disorders When how to apply
techniques

• Post-Traumatic Stress Disorder
• Features
• Exposure to extreme trauma e.g. that threatens
  life
• Recurring images of the trauma
• Distress triggered by similar events persistent
  hyperarousal
• Avoidance of cues/reminders of trauma

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Common Anxiety Disorders When how to apply
techniques

• 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

29
Common Anxiety Disorders When how to apply
techniques

• 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

30
Common Anxiety Disorders When how to apply
techniques

• 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)

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Common Anxiety Disorders When how to apply
techniques

• 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 appts 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. _______________________________________

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Common Anxiety Disorders When how to apply
techniques

• 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.

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Common Anxiety Disorders When how to apply
techniques

• 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.
  ___________________________________

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Common Anxiety Disorders When how to apply
techniques

• 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?
  __________________________________________________

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Collaborative 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

36
Evidence for Psychological treatments of anxiety

• Evidence suggests that CBT treatment packages
  Behavioural treatments (especially
  exposurebased) 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
  RCTs w/out double blind placebo control)

37
Evidence for Psychological treatments of anxiety

• 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

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Evidence for Psychological treatments of anxiety

• 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

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Evidence for Psychological treatments of anxiety

• In spite of evidence that CBT works, singularly
  effective ingredients not been identified for the
  anxiety disorders they improve. Its 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)
• psycho-education
• verbal discussion techniques
• imagery modification
• attentional manipulations
• exposure to feared stimuli
• behavioural experiments, such as manipulation of
  safety behaviours (e.g. avoidances)

40
Evidence for Psychological treatments of anxiety

• 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

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Resources

• My web page www.fmcdonald.com
• (Copies of stress manuals, anxiety
  management h/os, Behavioural and Auto-suggestion
  strategies for sleep, CBT for Psych Registrars
  presentation etc)
• Centre for Clinical Resources http//www.cci.hea
  lth.wa.gov.au/index.htmlLots of practical
  resources for pts and professionals alike
  covering a range of common psychological issues.
  Concise but comprehensive, clearly and
  attractively presented.
• Australian Govt Health Insite http//www.healthi
  nsite.gov.au/topics/Causes_and_Treatments_of_Anxie
  ty_Disorders

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Resources

• 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_guide
  line_popup.cfm?guidelineID38

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Optional Self-test

• 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?
• Describe and discuss the various psychological
  treatments that are currently used in the
  treatment of Panic Disorder with Agoraphobia.
• 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 mans medical illness,
  anxiety and depression?
• 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 cant switch
  off. So you suspect cognitive anxiety causes.
  What can you suggest in terms of self-management?

44
Optional Self-test

• 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.

45
Optional Self-test

• 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?