CBT for Complex Anxiety Disorder Cases

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CBT for Complex Anxiety Disorder Cases
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A MODEL OF ANXIETY
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Model of Anxiety

• STRESS
• Physical
• Psychological
• Long-standing
• Mystified

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Model of Anxiety Trait Anxiety

• Neuroticism/Trait Anxiety
• Andrews et al (1991)
• Torgerson (1983)
• Zinbarg Barlow (1996)

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Model of Anxiety Trait Anxiety

• People inherit a tendency to be a nervous person,
  rather than a tendency to develop a specific
  disorder

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Model of Anxiety Breathing

• Role of Overbreathing
• Exacerbates symptoms

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Model of Anxiety Alarms
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Model of Anxiety False Alarms

• Three strategies
• replacing inaccurate with accurate information
• explaining origin (and benign nature) of symptoms
• reiterating purpose of fight or flight response

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Cognitive Model (Clark, 1986)
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Treating components in the model
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EXPOSURE

• Processes

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Exposure What predicts avoidance?

• Not severity of frequency of panics
• Not Age of onset
• Not duration of panic or location of first panic
  (unclear)
• Negative outcome expectancies
• Perception of link between situation and panic
  occurrence
• Self-efficacy

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Exposure What predicts avoidance?

• Therefore, exposure should aim to
• Change outcome expectancies (instruction and
  experience)
• Modify perception of link (change causal
  assumptions)
• Enhance self-efficacy (control strategies)

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Exposure How much anxiety?

• Aim to expose to anxiety, therefore as much as
  possible
• Aim to change cognitions, therefore as much as is
  manageable

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Exposure Principles

• Resemblance of Real Situations
• More Frequent
• Longer (until anxiety ?) Better
• Dont Permit Escape ... But
• Change Cognitions
• Graded not necessary, but more pleasant

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Exposure Client Preparation

• Use relaxation before you go out
• Mentally rehearse at the end of relaxation
• Perform activities in a slow relaxed manner
• Monitor breathing rate
• When anxious Stop, breathe, wait until OK
• Dont leave until calming down and remain as long
  as possible
• Reward yourself for success

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EXPOSURE

• Problems

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Exposure Problems

• Dispense with steps
• Too many steps or go slowly
• Therapist timidity
• Distraction

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Exposure Problems

• Penfold Page (1999)
• Oliver Page (in press)

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Exposure Problems
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Exposure Problems

• Ungradable goals
• Confusing means and ends
• Aim is not to do the exercise, but to control
  anxiety when doing it
• Failure of fear to habituate
• thoughts maintain the anxiety
• arent using anxiety reducing techniques
• other?

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Exposure Problems

• Obsessive-Compulsive Disorder
• Exposure to what?

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Exposure Be Patient
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Exposure Be Very Patient
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Exposure Be Very Very Patient
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Exposure Be Creative
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Exposure Keep Being Patient
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INTEROCEPTIVE EXPOSURE
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Interoceptive Exposure

• One trigger of panic is bodily sensations that
  are misinterpreted.
• The aims are to
• produce sensations repeatedly until they no
  longer trigger anxiety
• disprove beliefs about these sensations
• practice anxiety management skills
• Aim not to produce a panic, but the sensations

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Interoceptive Exposure
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HYPERVENTILATION
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Role of hyperventilation

• overlap with panic
• occurs during panic
• not necessary or sufficient

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Treatment - slowed breathing

• Stop
• Hold breath and count to 10 (seconds)
• Breathe out slowly, saying relax (through nose)
• Breathe in and out in a six second cycle
• At end of each minute return to step two if
  symptoms havent gone away.