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MH - CBT and Anxiety May05

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COGNITIVE BEHAVIOURAL THERAPY and ANXIETY

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.

Shire GPs May 2005


Key CBT Strategies
1. Controlled Breathing Exercise
Anxiety may take the form of general worry, obsessive thinking or panic attacks.
Increased rate of breathing is a common symptom of anxiety and can in itself lead to
hyperventilation and its associated symptoms (light-headedness, dizziness, pins and
needles). Learning to control breathing rate is a common and effective strategy in the
treatment of anxiety disorders.

Monitoring Breathing Rate


At rest the average person needs only 10-12 breaths per minute. If the breathing rate
is greater than 10-12 breaths per minute, the individual could be encouraged to
reduce his or her rate of breathing.

• 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:

• Tensing the muscles so as to recognise the feeling of tension


• Relaxing the muscles so as to feel tension flowing out of the body

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.

For maximum benefit, the patient is instructed to be an active participant, committed


to daily practice for two months or longer

In addition to regular relaxation sessions, a simplified version of the exercise can be


used throughout the day in any situation whenever the individual notices tension in
any particular muscle group (e.g., the abdomen or the shoulders). Targeted muscle
relaxation can help maintain lower tension levels throughout the day.

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.

Shire GPs May 2005


3. Thought Monitoring and Challenging
Assisting a patient to monitor and examine their thoughts for inconsistencies and lack
of supportive evidence and, where appropriate evaluating these thoughts to arrive at a
more realistic perspective, has been demonstrated to be an important part of
overcoming anxiety and preventing relapse.

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:

Principles of Graded Exposure


1. Provide training for the controlled breathing and relaxation exercises. These
exercises can be used before starting each step of the graded exposure
hierarchy to ensure that the individual is calm and relaxed at the beginning of
each session. Controlled breathing and targeted muscle relaxation can then be
used in the feared situation.

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.

Shire GPs May 2005


Sample Graded Exposure Plan

Problem: Panic attacks and fear of leaving the house

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.

1. Sit on the front verandah for 20 minutes (anxiety rating 3/10).


2. Walk to the letterbox to collect the mail then remain in the front garden for 20
minutes (anxiety rating 4/10).
3. Walk around the block once (anxiety rating 5/10).
4. Walk around the block twice (anxiety rating 6/10).
5. Walk up to the post office at 10 am when it is not busy and buy a stamp (bring
stamp in for inspection) (anxiety rating 7/10).
6. Catch a bus to the shopping centre, get out and wait for the next bus, then return
home (bring bus tickets in for inspection) (anxiety rating 8/10).
7. Catch a bus to the shopping centre, go to the florist, buy a bunch of flowers as a
reward, walk around the centre for another 15 minutes, then return home (anxiety
rating 9/10).
8. Catch a bus to the shopping centre on a Saturday morning, catch lift up to car
park then escalator to come down again, go to supermarket and buy 16 items
from shopping list (retain docket), then return home (anxiety rating 10/10).

Overcoming Problems during Graded Exposure


Consider the following questions if problems are encountered during graded
exposure therapy:

Is the individual trying to progress too quickly or too slowly?


Tasks that are too easy are not rewarding and tasks that are too difficult are
demoralising. The secret to success is regular and gradual progress.

Has the individual had enough practice at this step?


It is important that the individual masters the present step before moving on to a more
difficult step. Some steps are more difficult than others hence the individual may
need to progress more slowly at times. Moving on without sufficient practice can lead
to loss of self-confidence and motivation if the individual experiences a setback at the
next step.

Is the increase in difficulty between steps too great?


If so, intermediate steps may need to be added so that the increase in difficulty is
more manageable.

Is the individual using breathing control and the relaxation method PRIOR TO AND
DURING the exposure exercises?

Shire GPs May 2005


These techniques will help the individual feel calmer and more in control. However,
these techniques require practice so it is sensible for the individual to master these
techniques before commencing with 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?"

Remember that setbacks DO occur.


If a setback occurs it may be helpful for the individual to return to a previous step at
which he or she feels more comfortable. It will also be helpful to encourage the
individual to view the setback in a positive light.

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.

Problem solving is a powerful alternative to the anxiety patient's worry. For


Generalised Anxiety Disorder it is especially helpful.

How to help patients help themselves?


The above strategies are skills the patient needs to learn. Knowledge of the skill is
unlikely to be effective unless the patient uses the skill in their everyday situations.
This means the patient needs to be an active participant in the treatment of his/her
symptoms.

Passivity is not an uncommon feature of patients presenting with anxiety/depression.


Orientating the patient to Self-Help will be crucial. To do this one can emphasise that
the patient plays an important role in therapy and that any medication prescribed is
largely designed to help the patient help themselves.

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.

Trouble Shooting the Strategies


The tables below are an attempt to identify some of the common pitfalls patients
experience in trying to learn and apply these strategies along with some suggested
solutions.

Shire GPs May 2005


TROUBLE SHOOTING PROBLEM SOLVING in ANXIETY
Problem Possible causes Suggested solutions
1. Chosen problem is vague and poorly 1. Return to problem definition and
defined attempt to define problem in more
specific manner.
2. Chosen problem is too hard 2. Attempt easier problem or breakdown
Individual unable to generate possible problem into smaller problems
solutions to selected problem 3. Individual may be analysing solutions 3. Reinforce idea of generating all
with regards to their usefulness rather possible solutions without evaluating
then concentrating on generating all each at this stage. Encourage this by
possible solutions suggesting some of your own to add to
list
1. Negative thinking style 1. Attempt Straight Thinking Module
Individual has negative “Yes but” 2. Negative expectations 2. Encourage a “Have a go and see”
approach to all possible solutions 3. Lack of motivation attitude

1. Solution beyond their capacity 1. Choose easier solution or easier


Individual unable to apply chosen solution 2. Solution requires participation of problem
others 2. Enlist help of others or choose
alternative solution which requires less
from others
TROUBLE SHOOTING HELPFUL THINKING in ANXIETY
Problem Possible causes Suggested solutions
Individual unable to identify thoughts 1. Unfamiliarity of task 1. Ask what was going through your head
at the time? What did you think was
going to happen to you?
Individual places feeling in thoughts 1. Unfamiliarity of task 1. Ask what was it about X that upset
column eg I was upset you?
Individual places thought in feeling 1. Unfamiliarity of task 1. Ask how does it feel being a failure?
column eg I felt like a failure
1. Individual confuses task. Perceives the 1. Reinforce positive thinking of little
Individual generates positive thinking in need to generate positive thought value. Rather need to generate
place of realistic alternative thought rather then realistic thought alternative thought based on evidence
which is at least to some degree
believable to the individual
Individual unable to come up with 1. Unfamiliarity with task 1. How would you prove this to someone
evidence to support thought else?
1. Rigid, Black and White thinking style 1. Ask how someone else might
Individual insists there is only one way of perceive it? Ask what benefits there
perceiving situation in question may be from perceiving it differently?

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