MH - CBT and Anxiety May05
MH - CBT and Anxiety May05
MH - CBT and Anxiety May05
Introduction
Cognitive Behaviour Therapy has been shown to be a very effective treatment for
Anxiety problems. Further CBT based strategies have been successfully used in the
form of Self-Help manuals. When combined with medication, CBT has been shown to
be useful in preventing relapse once medication is reduced or ceased.
What is CBT?
Cognitive Behaviour Therapy (CBT) is based on the theory that, how a person thinks
about a situation and what they do has a significant influence on how they feel. In the
case of anxiety these thoughts typically involve a threat to the individual's health,
financial or social situation. This theme of "threat or danger" is critical in
understanding anxiety symptoms.
In the case of Panic Attacks, the thoughts usually involve some physical illness (heart
attack, brain tumour) or some fear of loss of control (going mad, losing control in
public). The individual interprets their physical sensations during an episode (the
symptoms of anxiety) as evidence to support the idea that something bad is about to
happen. Accordingly they take some evasive action (eg avoid the situation) or
approach the situation with great care and using some form of safety mechanism
(mobile phone to call for help, drink to deal with dry mouth, medication within easy
reach).
In General Anxiety Disorder (GAD) the thoughts can often be more elusive and less
circumscribed but the theme of danger continues. One of the most common
symptoms of this type of anxiety is constant worry. In this context worry can be seen
as behaviour aimed at relieving the individual from anxiety. However worry is a poor
substitute for problem solving. In worry the individual never really follows a
systematic approach to their problem and hence is unlikely to arrive at an achievable
solution.
In all cases of anxiety it is crucial to look beyond the presenting symptom and search
for the underlying perceived threat. Once this has been achieved a number of
strategies can be utilised to challenge this assumption of danger (problem solving,
helpful thinking, graded exposure).
CBT is a relatively short term, problem focussed and evidence based approach to
psychological problems. As such, some of its strategies lend themselves to be used
both in a self-help context and in a context were limited time is available for therapy
(such as in a traditional GP practice). Further, although there are different levels of
CBT practice many of the fundamental strategies can be learned without the need for
previous skills and knowledge in the area.
• Ask the individual to count how many breaths he or she takes in one minute.
• Breathing in and then out is counted as one breath.
It will also be useful for the individual to monitor his or her breathing rate at other
times, particularly during times of stress or anxiety. Ask the individual to keep a
record of his or her breathing rate at various times and the activities engaged in at
those times.
In the Controlled Breathing exercise the patient is given instructions on how to monitor
and control their breathing rate.
2. Relaxation
A useful form of relaxation is the progressive muscle relaxation technique. This
technique involves:
The steps involved in the exercise are outlined in the handout provided. Additionally,
many music stores sell audio tapes that lead the listener through similar exercises
while listening to soothing music.
Other forms of relaxation may also be helpful and include meditation, hypnosis, yoga,
or tai chi. Some people also find aerobic exercise (e.g., swimming or jogging) of
great benefit. Patients are encouraged to find a form of relaxation that works for
them and use that routine regularly.
One of the important effects anxiety has on a person is to change the way they think
about things. They focus on a threat of danger of some form. The person with
anxiety has a tendency to look at the negative side of things, to see all the things that
have gone wrong in the past and the things that could go wrong in the future.
This section is one that further training will make significantly easier. It may be
necessary to refer to a specialist trained in CBT.
4. Graded Exposure
If the phobic avoidance is mild the following principles may be applied:
2. Help the individual plan a series of steps for the graded exposure hierarchy. The
first step is one that causes little anxiety, while the last step is one that causes
maximum anxiety (see sample plan on the following page). The individual can
plan these steps at home and bring them in to the next consultation for
discussion.
3. Help the individual identify any exaggerated fears that occur in each situation
(e.g., "I will faint “) and decide what is more likely to happen (e.g., "I am anxious
but I am unlikely to faint').
4. Encourage the individual to practise the first step of the hierarchy. He or she
does not move on to the next step until the previous step has been mastered with
minimum anxiety. Continue this process until the person can manage all
situations in the hierarchy.
5. Identify a friend or family member who can provide support and encouragement.
6. Encourage the individual to avoid using alcohol or drugs to cope with feared
situations.
7. If fears continue after the above methods have been tried, seek consultation
from someone who has specialised training in the behavioural principles of
graded exposure.
After mastering the controlled breathing and relaxation exercises, the individual could
embark on the plan below (developed in conjunction with the individual according to
his or her specific fears).
It is important to ensure the individual uses the slow breathing and relaxation
exercises before and during each step, and especially when panic attacks occur.
The individual is instructed to persevere at each step until the step can be performed
with minimum anxiety. Only then does the individual move on to the next step.
Is the individual using breathing control and the relaxation method PRIOR TO AND
DURING the exposure exercises?
Is the individual identifying exaggerated fears and replacing these fears with thoughts
about more likely outcomes?
Encourage individuals to ask themselves questions such as:
"What EVIDENCE is there that a particular event or response is going to happen?"
"REALISTICALLY, what is the WORST thing that can happen? "What if.... DOES
happen? Will it really be so bad? What is MORE LIKELY to happen?"
5. Problem Solving
The problem-solving model is a common strategy in a CBT orientated approach. It is
by no means unique to it, as this model is widely used across a range of areas. A
number of studies have demonstrated that, using a Problem Solving approach, GPs
can make a significant impact on their patients’ anxiety symptoms.
Giving the patient clear instructions on what you expect them to do with the CBT
material will be important. When the patient next attends, asking the patient for their
homework should be high on the agenda for that session. Discussing how they went
with the homework and examining what problems arose in completing it, will continue
to emphasise to the patient that self help is important and expected from their treating
Doctor. This should all be done in a supportive, understanding manner.
It will also be important that you become familiar with the patient material. It will be
hard to convince the patient that these strategies are worthwhile, if they gain the
impression you have not spent the time to learn about them yourself.