Anxiety Disorders and Phobias: Aaron Beck

    

Anxiety Disorders and Phobias: Aaron Beck

Contents

Contents
Chapter 1 Turning Anxiety on its head: an overview    9
The Paradox of anxiety    9
Changing Concepts of Anxiety    9
Distinguishing Anxiety, Fear, Phobias and Panic    9
Anxiety and Fear    10
Phobias and Panic Attacks    10
Realistic and Unrealistic fears    10
Hoch’s paradox    10
Future Danger and present dangers    10
The function of anxiety    10
Adaptational aspects    10
Anxiety as a strategy in response to threat    10
Survival mechanisms    10
Summary    11
Chapter 2 Symptoms and their significance    11
Systems and Symptoms    11
Symptoms and functions    11
Major Reactions: mobilisation, inhibition, demobilisation    12
Free floating anxiety, fact or artefact    14
Normal versus pathological anxiety    14
Thinking disorder in clinical anxiety    14
Attention, concentration and vigilance    14
Alarm systems and automatic thoughts    14
Loss of objectivity and of voluntary control    14
Stimulus generalisation    14
Catastrophising    15
Selective abstraction and loss of perspective    15
Dichotomous thinking    15
Lack of habituation    15
Classification of Anxiety disorders    15
Summary    16
Chapter 3 The Cognitive model of threat reactions    16
The Role of Context    17
Primary appraisal    17
Secondary appraisal    17
Estimate of danger    17
Hostile Response    17
The Nature of Cognitive Processing    17
The relation of behavioural activation and inhibition to motivation    18
Distinguishing between behaviour and emotions    18
The vicious cycle    18
Primal Responses to threats    18
The anergic and the energic systems    18
Changes in cognitive content and physiological reactions    19
The relation of anxiety to other defensive responses    19
Summary    19
Chapter 4 Cognitive Structures and anxiogenic rules    20
Cognitive Schemas    20
The function of the cognitive set    21
The continuous Cycle    21
The Modes    21
Syndromes and modes    21
Assumptions, rules and formulas    22
Rules in problematic situations    22
Rules in Anxiety Disorders    22
Summary    22
Chapter 5 Vulnerability: The core of anxiety disorders    23
The Concept of vulnerability    23
The role of skill deficits    23
Self-doubt    23
The role of context and experience    23
Interference with effective performance    23
Catastrophic predictions and vicious cycles    24
The function of dysfunctional behaviours    24
Physical danger    24
Psychosocial danger    24
The domains of vulnerability    24
Sectors of the domain    24
Threats to the domain    25
Threats to sociality    25
Threats to individuality    25
Specific fears    25
Summary    25
Chapter 6 Generalised anxiety disorder and panic disorder    26
General View of the Etiology of Anxiety Disorders    26
Precipitating psychological factors    26
Interaction of precipitating factors with previous problems    27
Do Cognitions cause anxiety disorders    27
Generalised Anxiety disorder    27
Symptomatology    27
Types of Generalised Anxiety Disorder    27
Specific Fears    29
Self-Concept in Generalised anxiety disorders    30
Self-Criticism in Anxiety and Depression    31
The difference between anxiety and depression    31
Panic disorder    32
Description    32
Meaning of Panic Attacks    33
Functional Analysis of panic attacks    33
Precipitation of panic attacks    33
Summary    33
Chapter 7 Simple phobias    34
Definition of Phobia    34
Differentiating phobias from fears    35
The refractoriness of phobias    35
Content of fears and phobias    35
Classification    35
Traumatic phobias    36
Fixation phobias    36
Specific phobias    36
The Meaning of Phobias    37
Multiple phobias: Conceptual continuity    37
Relation of fears to Phobias    37
Self-Confidence versus vulnerability    37
Dual belief System    37
Visual Images    37
Identification with Victim    37
Evolution, Rules and Phobias    38
Summary    38
Chapter 8 The Agoraphobia Syndrome    38
The Riddle of Agoraphobia    38
The Development of Agoraphobia    39
Predisposition and precipitation    39
Onset of symptomatology    39
Panic    39
Attribution of causality in panic attacks    39
Cognitive set: vulnerability    40
A Synthesis    41
Summary    41
Chapter 9 The Evaluation Anxieties    42
The Essence of Evaluation Anxieties    42
Before the fall    42
Common features of evaluative threats    42
Vulnerability    42
Status and ranking order    43
Self confidence    43
Rules and formulas    43
Automatic protective reactions    43
Social phobias and social anxieties    44
Paradoxes of Social anxiety    44
The fear of being evaluated    44
The primal defences    44
Differentiating Social Phobia from Agoraphobia    44
Situations that provoke the phobic symptoms    44
Somatic symptoms    45
The phenomena of Social Anxiety    45
Shame and social image    45
Fear of loss or love or abandonment    46
Public speaking anxiety    46
Test anxiety    47
A Synthesis    47
Summary    47
Chapter 10 Principles of Cognitive Therapy    48
Principle 1: Cognitive therapy is based on the cognitive model of emotional disorders    48
Didactic Presentation    49
Levels of fear    49
Principle 2: Cognitive therapy is Brief and time limited    49
Principle 3: A sound therapeutic relationship is necessary condition for effective cognitive therapy    50
Principle 4: Therapy is a collaborative effort between therapist and patient    50
Principle 5: Cognitive therapy uses primarily the Socratic Method    51
Principle 6: Cognitive therapy is structured and directive    51
Principle 7: Cognitive therapy is problem oriented    51
Conceptualisation    52
General strategies    52
Principle 8: Cognitive therapy is based on an educational model    53
Learning to learn    53
Principle 9: The theory and techniques of cognitive therapy rely on the inductive method    53
Principle 10: Homework is a central feature of cognitive therapy    53
Summary    53
Chapter 11 Strategies and Techniques for Cognitive Restructuring    54
Developing Self Awareness    54
Directing Patients    54
Strategies and techniques    55
Counting Automatic thoughts    56
Questions    56
Three basic approaches    57
Where’s the evidence    57
What’s another way of looking at it    58
So what if it happens    58
Summary    59
Chapter 12 Modifying Imagery    60
Induced Images    60
Delineating maladaptive patterns    60
Pinpointing cognitive distortions    60
Modification of induced images    60
Techniques for modifying images    60
Turn off technique    60
Repetition    60
Time projection    61
Symbolic images    61
Decatastrophising the image    61
Images and thoughts    61
Facilitating change in induced images    61
Substituting positive imagery    62
Substituting contrasting imagery    62
Exaggeration    62
Coping models    62
Imagery to reduce Threat    62
Escaping a worse alternative    62
Mixed Strategy    62
Future therapy    62
Goal rehearsal    62
Summary    63
Chapter 13 Modifying the Affective Component    64
Accepting the feelings    64
Reducing anxiety about anxiety    64
Reducing shame about showing anxiety    65
Normalising anxiety    66
Active Acceptance    66
Identifying Emotions    66
Action strategies    66
Activity schedules    66
Increasing tolerance for anxiety    67
Alcohol, stimulants, diet, stress    67
Maladaptive coping behaviour    67
Self-Observation    67
Positive Self instruction    68
Graphs and diaries    68
Concentration (or distraction) exercises    68
Relaxation methods    68
Emotional Review    68
Imagery methods    69
Metaphors    69
Repeated review outside the office    69
Owning ones emotions    69
Sequential reasoning    69
Correlational reasoning    69
Analogical reasoning    69
Emotional reasoning    69
The Payoff    70
Summary    70
Chapter 14 Modifying the behavioural component    72
Identifying Protective mechanisms    72
Motivation    72
Explaining the therapeutic approach to the patient    72
Blocks to learning    72
Educational devices    73
Futility of self-protection    73
Experiments    73
Graded steps or a gradual approximation    73
Hierarchy    74
Aids to exposure    74
Initiation technique    74
Self-instruction    74
Behavioural rehearsal    74
The use of significant others    75
Technical aids    75
Cognitive avoidance    75
The critical-decision technique    75
Surprise    75
Choice    76
Behavioural thought    76
The As if technique    76
Shame and other feared experiences    76
Developing self confidence    76
Agreeing    76
Disagreeing    77
Doing the unexpected    77
Making a mistake part of the show    77
Summary    77
Chapter 15 Restructuring a patients assumptions and major issues    78
Identifying Assumptions    78
Major issues    78
Identifying Major Issues    78
Positive and negative reinforcers    79
Psychological double    79
Development of major concerns    79
Acceptance    80
Competence    80
Control    80
Motivation and Major Concerns    81
Summary    81
Book Summary    81

Chapter 1 Turning Anxiety on its head: an overview

The Paradox of anxiety

One of the paradoxical things about anxiety is it seems to bring on what a person fears the most, so the person presenting is anxious so they stammer their words which is what they most dread. When anxiety is mobilised every part of the body responds, the physiological system, heart racing and sweating, cognitions, oh god I’m going mad, emotions pure terror and the behaviour of trying to escape.  Why does it give us these false results when we are merely speaking in front of people?

Here are some possibilities:

1.       We overestimate the importance of the event as about life and death

2.       Prehistorically this is how we acted

3.       Evolution favours anxiety and false positives

The idea is that before the initial stimulus, a thought or an image appears that then stimulates an anxious response.  Thus if I my heart beats quickly and I think I’m going to have a heart attack and die, then an anxious response is appropriate. We often have these thoughts and images too quickly to notice.

Changing Concepts of Anxiety

Much clinical work has focus on the feeling of anxiety, presumably as this is the thing we most want to get rid of as it’s a very unpleasant feeling.  However it’s the cognition that follows immediately after the initial stimulus that creates anxiety. The effect of anxiety is the one that we want to get rid of the thing that motivates us to action but it is not the locus of the treatment it is the symptom, rather like pain is for a nail in the foot

Distinguishing Anxiety, Fear, Phobias and Panic

Fear: the feeling evoked by a judgement something dreadful will happen. It is a cognitive process. It is directed to the future.

Anxiety: this comes from the Latin word to choke and is the feeling similar to fear but without the object. Anxious is on the anxiety spectrum which ends up in panic. Anxiety seems like the affective aspect of fear without the appraisal aspect.

Phobia: An exaggerated fear of something. Come from Phobos which is Greek for flight

Panic: sudden overpowering fright and a frantic desire to find safety, it is a high state of anxiety

Anxiety has had useful responses, where it freezes us from further action, i.e. stops us going over the ledge or into the woods at night. It is useful where there is a real danger and an inability to cope with that danger. Thus it changes as we grow up, we are less anxious about strangers the bigger we get.

Anxiety and Fear

Fear is the judgement something terrible will happen, anxiety is the affective response to something terrible happening

Phobias and Panic Attacks

Phobia judges something as highly dangerous that others see as safe. The outcome of a phobia is anxiety or panic. Phobias are fears of the consequence of something.

Realistic and Unrealistic fears

You can apply the words realistic and unrealistic to cognitive processes like fears, but not to affective ones like anxiety. Freud saw anxiety working in two ways one to external threats which he saw as normal, and one to internal threats, i.e. repressed desire becoming manifest which he saw as pathological.

Hoch’s paradox

Why does anxiety impair our ability to perform, it seems to make things worse, when we get fight or flight responses this seems adaptive but freezing doesn’t seem so.

Future Danger and present dangers

Fear is future based something terrible will happen, anxiety is something terrible is happening.

The function of anxiety

Adaptational aspects

In the development of our species anxiety has been useful.:

1.       Fear and anxiety prevent risky behaviour, so freeze before stepping over the cliff

a.       Childhood has a lot of anxiety making events, strangers, roads, the dark, leaving mummies side

Explanation of current distresses

1.       Agoraphobia: could have had roots in being vulnerable to attack away from the pack or the covers

2.       Public speaking: roots in the dangers of being socially alienated

Anxiety as a strategy in response to threat

Anxiety gets attention and we really want to stop the feeling of anxiety. It helps us move away from dangerous situations and from taking careless action. In anxiety disorders we have a misinterpretation of a danger signal that is causing the anxiety, so there is nothing to get away from.

Survival mechanisms

There are different classes of fast reaction to feared situations. The more volitional they are the slower their response is:

1.       Anxiety reactions

2.       Reflex reactions: gagging, coughing, blinking, ducking, dodging, loud bangs

3.       Defensive patterns: tightening muscles, shallow breathing

One of the problems of anxiety disorders is the lack of flexibility to stop being anxious when the danger has gone.

Summary

Anxiety is a very strong feeling that makes you want to get the feeling to stop. Anxiety is the current affective response to being in danger, like pain is the current response to being in pain. Fear is the judgement that something bad is going to happen, anxiety is the feeling that something bad is happening, or just about to happen.

Whilst fear is a cognitive response and anxiety is an emotional response, an anxiety disorder stems from a cognition. So something happens, my heart beats fast, then there is a cognition I’m having a heart attack and going to die. Anxiety is then the response to the feeling that I’m dying.

The evolutionary purpose of anxiety is to stop a person adopting risky behaviour and also to be able to pass on rules through the ages, so the tribe says don’t go to the woods at night or bad things happen, as they have found this out and taken this as an accept rule. Obey rules or you lose social support, so anxiety polices the rule to say don’t go to the woods at night.

Chapter 2 Symptoms and their significance

Systems and Symptoms

Anxiety can be understood in terms of its function to the overall system.  Evolutionary master objectives are self-preservation, feeding and breeding and subsystems are said to be adaptational when they fit into that. Each subsystem reacts differently to different situations and to different master plans and it is the cognitive system that controls this. Our cognitions sees the relationships between things, between perceptions. The things most vital to our interests are survival and sex, thus it is likely that anxiety disorders have some relation to sex and survival in them.

When cognition selects anxiety as the affective response this have the effect of speeding up the system.  One of the problems however of choosing anxiety is that it isn’t that flexible and you can’t switch from one subsystem to another and turn it off. Even when the danger goes, then anxiety doesn’t switch off. There are many aspects to fear and danger, from getting a sense the situation is dangerous to perceiving the dangerous aspect, to understanding what coping mechanisms are available to selecting and implementing them. There are a variety of subsystems involved in this process thus the reaction to fear and danger is not a simple one.  You can also get clash of strategies fight and flight that adds complexity to the response.  A person can be in a situation where their wishes and fears clash. I wish to speak, speaking is a danger to me. The danger response is a primal.

Symptoms and functions

Anxiety affects 4 subsystems

1.       Cognitive

2.       Affective

3.       Physiological

4.       Behavioural

Anxiety is from a primal subsystem and can overtake more mature responses.

Cognitive Symptoms in Anxiety disorders

1.       Sensory

a.       Mind hazy, cloudy foggy

b.      Objects seem blurred

c.       Environment seems unreal

d.      Self-conscious

e.      Hyper vigilant

2.       Thinking difficulties

a.       Can’t recall important things

b.      Confused

c.       Unable to control thinking

d.      Difficulty in concentrating

e.      Difficulty in reasoning

f.        Loss of objectivity and perspective

3.       Conceptual

a.       Fear of

                                                               i.      Losing control

                                                             ii.      Going mad

                                                            iii.      Not being able to cope

b.      Frightening visual images

Whilst the above cognitive symptoms are experienced by most people some of the time, they generally ignore them. With people with anxiety disorders then they are taken as symptoms of an anxiety disorder or madness etc., but certainly the symptoms fuel the symptoms.

Thinking difficulties may be because all attention is there for dangerous items and no energy is left over for other ways of attention however this seems unlikely as the cognitive functions just seem impaired rather than good in some areas and bad in others.

If anxiety is immediate and severe it is likely to be experienced as panic, if it is long lasting then it is more likely to be experienced as unease or a wound up feeling.  Anxiety behaviour can either be a freezing or the tremors of restless activity.

Major Reactions: mobilisation, inhibition, demobilisation

Three types of reaction to danger

1.       Mobilisation

a.       Prepares the individual for active defence

b.      Cognitive: Hypervigilant for danger

c.       Affective: edgy, tense and terror

d.      Behavioural: increase in muscle activity, restlessness continual movement

2.       Inhibition

a.       Curtails risky behaviour buys time to aid decision

b.      Cognitive: functions are impeded a sense of passing out

c.       Behavioural: inhibition  of spontaneous movements, face therefore may appear blank

3.       Demobilisation

a.       Deactivation of defences in the face of overwhelming threat

b.      Symptoms are weakness and fainting

Affective adjectives for anxiety

1.       Edgy

2.       Impatient

3.       Fearful

4.       Scared

5.       Uneasy

6.       Nervous

7.       Tense

8.       Wound up

9.       Anxious

10.   Frightened

11.   Alarmed

12.   Terrified

13.   Jittery

14.   Jumpy

Behavioural symptoms of anxiety

1.       Inhibition

2.       Tonic immobility

3.       Flight

4.       Avoidance

5.       Speech dysfunction

6.       Impaired coordination

7.       Restlessness

8.       Postural collapse

9.       Hyperventilation.

Free floating anxiety, fact or artefact

When questioned the anxious person always has a feeling that something bad is going to happen.  His attention then becomes selective to only those things that show that he is in danger. Anxiety only appears free floating or without cause as we do not understand the clients world. If a client doesn’t get what they are anxious about then they don’t understand their world either.

The psychological core of anxiety is a fear of

1.       Physical disaster

a.       Death

2.       Mental disaster

a.       Going mad

3.       Social disaster

a.       Making a fool of yourself

Normal versus pathological anxiety

If there is a real danger and the level of anxiety accords to that and diminishes when the danger goes then anxiety is deemed normal and pathological outside of that realm.  However the boundaries are unclear and pretty much sociocultural constructs.

Thinking disorder in clinical anxiety

Attention, concentration and vigilance

Attention is reduced, concentration is impaired. However all cognitive systems are pointed to one thing, thinking about danger, possible danger and actual danger. Thus using his cognitive system to be hypervigilant for danger then he has less energy left for any other tasks.

Alarm systems and automatic thoughts

Anxiety disorders can be conceived of as a hypersensitive alarm system. Negative automatic thoughts tend to keep the feeling of danger in focus and keep the alarm system on hypersensitivity. It can be difficult to be aware of some of these thoughts, they can sometimes be so fleeting that the only thing you are aware of is the anxiety generated. Likewise they have been thought so often you don’t pay attention to them and again just act on them.

Loss of objectivity and of voluntary control

Objectivity can be lost a client logically can say they don’t believe their thoughts about danger but they act as if they are true. Another aspect of anxious thinking is there’s a large degree of involuntariness about it, which adds to the out of control feeling.

Stimulus generalisation

The original cause of anxiety can be generalised to things associated with the original, so the effect of anxiety moves to more things, is associated with more situations and more antecedents. 

Catastrophising

Anxiety sufferers catastrophise quite a lot, they see events in dangerous, so sees a negative outcome and an inability to cope with it.

Selective abstraction and loss of perspective

Selective abstraction: people only see part of the picture, the dangerous part, they blank out aspects of a situation that would mean that there is safety, that you can cope

Dichotomous thinking

Dichotomous thinking: again anxious folk see black and white, dangerous or not, there is no space for ambiguity or uncertainty. As they get closer to the danger then the level of absolute, catastrophic thinking increases.

Lack of habituation

After repeated exposure to anxiety normal people become habituated to it where as people with anxiety disorders don’t. The thinking being that a normal person will understand that an event isn’t threatening, so even if it could be, it is understood that it isn’t, whereas an anxious person sees that as it could be a threat then it probably is.

Classification of Anxiety disorders

1.       Panic disorder

a.       Recurrent anxiety attacks happening at possibly unpredictable times

b.      Feeling of nervousness between attacks

2.       GAD

a.       Ruminates about a wide range of things

b.      Can’t better be described by one of the other classifications

3.       PTSD

a.       Follows  a psychological experience outside of general human experience

4.       Atypical anxiety disorder

a.        this is the miscellaneous when none of the other fit

5.       Phobic disorders

a.        Irrational fear of an object/activity. The fear is recognised by the individual as unreasonable.

6.       Agoraphobia

a.       Fear of being alone or being in public places from which escape in case of incapacitation might be impossible

7.       Social phobia

a.       Avoid situations where you can be under the scrutiny of others. Fear of being humiliated or embarrassed

8.       Simple phobia

a.       Fear of spiders, heights etc., can’t really see the difference between phobic disorders apart from the individual sees them as irrational.

Summary

So anxiety is an affective response which can be used as part of a cognitive appraisal of a situation. Choosing it, if that’s what we do speeds up the components of the system.  Anxiety as a response is deemed to be adaptive if it reflects the level of danger, and our ability to cope with it poses.  The anxiety response is quite a primal response to danger, and is likely to be related to some of our base needs survival and sex.  Anxiety disorders happen when there is a misinterpretation of the signs of danger, so it’s like having a hyper sensitive alarm system. Thus all the various subsystems go into a state of hyper vigilance. The attention is only aware of possible danger, hyper vigilance of perception can be to look at the body for signs of impending doom, or the environment for signs that disaster is on its way. Cognitions only respond to thinking about dangerous things.  Anxiety is a powerful feeling that we want to stop. The thing is that like pain we need to find the cause of pain and get rid of that rather than find a way that we can stop feeling pain, or as soon as that balm wears off it will come back again.

The anxiety response does a number of things:

1.       Speeds up response

2.       Can close down systems so that all attention is given to danger

3.       It can inhibit systems so that no danger is created through activity

4.       It can play dead so that the beating that will come can be ridden

I do wonder if the propensity to anxiety attacks is similar to the level of avoidant behaviour. It seems that to stop is an aspect of the anxious reaction to danger.

Chapter 3 The Cognitive model of threat reactions

Perception is like using a camera you trade of features of the scene to make the shot.  People have first impression to a scene that determines if the situation is of interest and if it requires a critical response.  The emergency response is to a clear and present danger

When we first do our appraisal of what a scene means then we include possible dangers which on subsequent reappraisal are ignored, in anxiety disorder this isn’t the case.

Thus we have primary appraisal, secondary appraisal and reappraisal

Example of Primary appraisal would be:

1.       Is the current situation a threat to me?

2.       Use general perceptual engagement, perception if you like rather than reflection

Secondary appraisal would be

1.       What are the resources I have to deal with it

2.       What method of attention should I give to the scene

3.       What is the likelihood of the danger happening

Fight, flight, freeze or faint. As the primary and secondary appraisals happen they are not intentional but happen very quickly

If the danger is coming from a situation that the client thinks they have the power to overcome then there can be a hostile response, shouting, staring down, and attacking.  Fighting can also be done as a last resort, as a way of slowing the predator down.

The Role of Context

Appraisal is broken down into primary, secondary and reappraisal, which is a process of progressive scanning of finding specific focus within a scene. Primary appraisal is about vital interests

Primary appraisal

This provides information that either reinforces or modifies an existing cognitive set, and concerns whether something concerns someone’s vital interests, if this is a perception of vital interest then this calls for a critical response. So vital interests are survival, individuality, functioning, if there is a threat to these then this call for an emergency response. The type of response is global, absolute and arbitrary; it is therefore very fast. Actual threats use primary appraisals to generate emergency responses, although there are also possible threats which in anxiety disorders are where the problems are. So false alarms from possible threats are not turned off either because a reappraisal doesn’t happen or it does and the alarm still isn’t turned off.

Secondary appraisal

Secondary appraisal is working out what resources you have to deal with the threat, which can be internal or external.  As this secondary appraisal happens there is also a sum that is made that relates the level of danger to the ability to cope which then produces the intensity of one’s response. Primary and secondary appraisals happen at such speed we may not even be aware of them, or if we are then they can be fused into one.

If the threat is low compared to his coping mechanisms then he may fight, if they are high then he may flight, freeze or faint.

Estimate of danger

On the size of the danger and size of your coping responses you work out if you will fight or flight. The degree of mobilisation and of subjective anxiety is relevant to the degree of danger perceived. The degree of fear is relevant to the estimate of potential damage anticipated and the probability of it occurring.  So there is a decision point whether to fight or fear something. Then there is the estimate of the level of danger to self, i.e. threat less coping. Then there is the probability.

Hostile Response

We can fight if we think we have a chance of winning and our resources are greater than the threats, we can also increase our feelings of our own resources by self-confidence, and contextual items, e.g. helper. If we are back into a corner and have nothing left to lose we can also fight but this is on the basis of anxiety, and we are trying to minimise expected damage.

The Nature of Cognitive Processing

Bowlby states that before we are aware of a stimulus coming through our senses we have already done much processing of selection, interpretation and appraisal that excludes much of the incoming material as we only have limited capacity on our senses, so we have to reserve this for the good stuff.

The nature of this pre conscious selection is on the basis of what is best for us. When you are hungry you will see the world in food terms, when horny in sexual terms etc. In an emergency response all that is seen is danger, which is odd as what about means to cope with danger, or safety etc.

The relation of behavioural activation and inhibition to motivation

Primal responses seem to operate on the automatic scale of things. Motivation is therefore applied to volitional areas.

Distinguishing between behaviour and emotions

How come people see venting your anger is good, but venting your anxiety is not so.  The emotion of anxiety as opposed to its behaviour, i.e. the feeling can only be created involuntarily so you have to recall a certain anxiety provoking situation to get anxiety, whereas you can act anxiously. As we encounter a fearful situation we judge it as such as fearful, then we get anxious about this, and this anxiety reinforces the judgement of the fearful situation. We are behaviourally activated and motivated

The vicious cycle

The vicious cycle is where a response to a dangerous situation is seen as a threat itself, then as the danger increases so does the threat.  So the feeling of anxiety may reinforce the feeling of vulnerability and therefore increase its intensity. So if you have your situation and anxiety, and anxiety disorder interprets the levels of anxiety as the levels of the problem, not the levels of the situation. People who have to be in control are more susceptible to anxiety disorders as they can’t accept not being in total control and paradoxically this makes things worse.

Primal Responses to threats

1.       Fight which can be defensive or aggressive

2.       Flight instigated mainly by anxiety

3.       Freeze, just prior to attack, gives time to appraise the situation and decide best course of action, also prepares the body to absorb the impact, it can also be to prevent continuing dangerous action like walking off a cliff

4.       Faint, happens when someone is overwhelmed, it is a play dead response, in the hope that the threat will pass them by

5.       Duck\Dodge\Jump: evade missiles

6.       Clutching\Clinging: helping to maintain balance

7.       Reflexes: gagging\blinking\coughing

8.       Calling for help

The anergic and the energic systems

Sympathetic nervous system relates to fight\flight

Parasympathetic relates to rest and digest relates to feint\freeze

There is a sense when one system can be activated and can be the predominant response, fluid movement between the two doesn’t seem to happen, but rather on the basis of a primary appraisal then one system is activated.

Changes in cognitive content and physiological reactions

The choice of nervous system response is determined between the fight or fear response. If the former then you get a sympathetic response if the latter then a parasympathetic response.

If you are injured then you can get a parasympathetic response where systems close down, this is the shock reaction to minimize activity to prevent further injury.

People can also imagine that something is going to happen, so they will be injured or such like and you can get a strong parasympathetic response in this instance. This is where the response isn’t adaptive as the problem hasn’t happened.

The relation of anxiety to other defensive responses

There are other responses to reduce anxiety, but they can appear also without anxiety being there, they may well happen when anxiety is low:

1.       Counterharm strategies

a.       gagging

2.       Ducking, flinching

a.        

Reflexive behaviours work quicker than intentional responses which are the domain of anxiety. Anxiety calls up volitional movement, reflexive movements but as the plan master it is slower than reflex.

Summary

Perception works on a funnelling aspect where there is a pre-conscious filtering\interpretation of the world at quite a low level. It is done on the basis of our bodily engagement with the world and our desires, so when hungry, tired, etc. you see the world differently to when you aren’t. The reason this happens is there is so much bandwidth in the senses so you have to be selective with what you offer to them. On the basis of this pre-conscious filtering then we see, hear, smell etc.

One level of low level automatic filtering that happens is whether something is of interest to us, to our concerns, if it is it takes our interest. On the basis of this, then there is the estimation as to whether it is a threat to our concern or a boon. This is called the primary appraisal, which determines is something of interest to us, what is the strength of this interest and is it positive or negative. If something is a threat to a vital interest, then this elicits an emergency response.

A secondary appraisal happens at that time which looks at the level of resources that you have to deal with that threat.

On the basis of the primary and secondary appraisal then you work out:

1.       Level of vital interest

2.       Probability of happening

3.       Ability to cope

The relation between these three factors produces the level of anxiety response. Anxiety tends to speed up processing as we want the feeling to go away.  If we think our resources are greater than the threat level then we adopt a hostile response, i.e. we fight, if not we adopt a fear response. The fear responses are:

1.       Flight

2.       Freeze

a.       This gives time to make a decision

b.      Prepares the body for blows

3.       Faint

a.       This plays dead and hopes the threat won’t take interest in me

So standardly anxiety functions as the outcome of a threat appraisal, it is the motivation to act quickly to respond to the threat. The type of response that is called for with anxiety is a volitional one. Anxiety isn’t as quick as reflexes which are the quickest to respond and aren’t volitional, whereas anxiety is not as fast but is volitional. 

On the basis of anxiety, then this is a prompt to deal with that which you are afraid of.  The difficulties with anxiety come when

1.       You are not sure why you are anxious

a.       This can lead to thinking there’s something wrong with you

2.       The signals for anxiety become something you are afraid of

a.       This means that your response to fear increases fear

Chapter 4 Cognitive Structures and anxiogenic rules

Predominantly we act on rules, interpretation and judgements rather than perceive fresh each time. Past experiences therefore impact on how we perceive, and can be reified as rules, or as cognitive structures. Cognitive structures contain rules, beliefs, memories and the like that guide interpretation, relevance and action. Sometimes a person oversees, so he more responds to his cognitive structure rather than what is actually there. 

Cognitive Schemas

Cognitive schemas are there to label, classify, interpret, evaluate and provide meaning to objects and events. They are derived from experience and instruction and contain, rules, beliefs and memories. When a schema is activated it can block out information that isn’t allowed by that schema, so if someone is hungry that can block out ideas about diet or exercise. With psychopathology then the anxious person can only see danger not safety, the depressed person only see negative things not positive things.  With anxiety that’s kind of weird as if the cognitive appraisals are correct, i.e. threat, coping resources=anxiety, then the perception for coping resources is already there. But with anxiety disorders, there’s the sense that the symptoms are a sign that something is wrong with me, I will go mad, or that will be humiliated.

When the symptoms of anxiety become something that is feared then this can make anxiety become worse to the point where fainting is the order of the day or freezing as the fear is so high now, that the client thinks they are either under attack now, or that they just can’t cope with the level of attack.

The content of the schemas will determine the affective and behavioural response.

The function of the cognitive set

Once a schema is invoked it can rapidly process data which is its point. I wonder what it’s like when we are between schemas or there is no active schema. Schemas are adaptive in that they allow us to processes the most amount of data that we can in the shortest of times.  A schema can often increase the number of false positives but decrease the number of false negatives, so in a danger schema, then there will be more times that something which isn’t frightening is identified as such but fewer times something that is frightening is identified as such.

Schemas can sometimes be turned on and off at will, so I decide to study and the studying schema is evoked. More than one schema can be evoked at any one time, so that the playtime mode maybe activated with the study schema which can create a clash of desires.

The continuous Cycle

Schemas can have cognitive, affective or behavioural content. So you might judge something as being sad, so that you then invoke the sad affective and behavioural schemas. You can also get a behavioural schema operating under a fear schema you aren’t that conscious of, and when you spot it happening, you can deliberately invoke a less fearful schema.  Thus you can get a behaviour that is activated then controlled, this you can usually see as not all of the behaviour can be controlled and it certainly doesn’t look like its desired outcome, so a nervous person forcing themselves to look relaxed doesn’t look like a relaxed person.

Anxiety is used to prompt for action which when taken should reduce the fear and signal the all clear signal, it is this latter aspect that doesn’t happen with people with anxiety disorders.

The Modes

Problems can occur when there is prolonged activation of fear and anxiety and this occurs when a person perceives his vital interests are at stake.  If danger schemas are activated for too long then you get distress, tremors, muscular tension, sleep disturbances.  If a schema is often used then it becomes habituated and it becomes the superordinate schema. These superordinate modes, can be narcissistic, depressive, erotic, fear or hostility. These dominant modes then effect specific schemas, so if you are taking a test, and you are in hostile mode, then you think bloody test, or if you are in depressive schema, then you think, "Oh my God, " I’m going to fail. S

Syndromes and modes

Various syndromes can be conceptualised in terms of the dominant schema

1.       Depression

a.       Self-constricting mode is dominant

2.       Anxiety

a.       Vulnerability of danger mode is dominant

Dominant schemas produce bias, both attentionally and in terms of recall.  So cognitive processing is biased by the dominant schema both in terms of perception and in terms of recall.

Assumptions, rules and formulas

Rules can operate at a preconscious level where they direct our attention and our interpretations, they have been used so many times that we are not aware of ourselves doing it.  Rules can be grouped in terms of theme, much like schemas can around modes.  Many rigid rules are there for rapid response, they seem too organised as a basic matrix of cognitive response and therefore hard to change.

Rules in problematic situations

Problems occur when you use rules in the wrong situations, or you don’t adjust your rules to suit your outcome.  Rules say how you should act, and how you interpret, thus rules are the basis on which we confer meaning to our world.  As much as there are rules, there are also assumptions which are standardly conditional if someone is nice, then they want something. Often rules and assumptions guide our interpretation of a situation and we are as unaware of them as of the rules of grammar that guide out language

Rules in Anxiety Disorders

Each distress has its own set of rules associated with it.  In anxiety the rules are about danger and vulnerability and are generally conditional if x happens then dangerous y which I can’t cope with.

Summary

We need to interpret the world in a certain way and judge if what is of interest, if it is positive or negative. We cant do this every time as otherwise we would be very slow in our actions. So what we do is to have schemas which is the congealing of rules, assumptions, beliefs, and memories, that determine how we respond behaviourally and affectively in a situation, they determine our perceptions and our interpretations on that which lead to action, behaviourally and emotionally.

Schemas have modes where they have certain aspects. Likewise schemas have different content type so cognitions, behavioural and emotional. You also have dominant schema so we might have a cognitive shcema in charge, saying I must study, and this may be in battle with the play schema that needs to have fun. The modes are the descriptions of schemas as depressive, hostile, loving, caring etc.  When a person habituates certain modes of schemas then they can naturally adopt these and they become quite inflexible. The problems with this is where the schema prevents sight of anything to dispute it, the rules which are used are used to prove themselves with evidence from the world rather than looking at the world to see if they are true.

Rules and assumptions are used so habitually to interpret, guide action and evaluate action that we forget the rules that we have much like we don’t the rules of grammer we use, just the impact

Chapter 5 Vulnerability: The core of anxiety disorders

The Concept of vulnerability

There is a paradox when anxiety prevents the simplest skills from operating at a time when we need them most, the clue to this is the concept of vulnerability, the feeling when  you are threatened.

Vulnerability is the person’s perception of himself as subject to internal or external dangers over which his control is lacking to afford him a sense of safety.  Where this sense of vulnerability is pathological is where there is a minimization of perception of personal strength and a maximisation of the sense of danger. There is  minimisation, selective abstraction and catastrophising to get to this point.  A person minimises their personal strengths, perceives the world as only threantening, selective abstraction and each slip a slide towards oblivion, i.e. catastrophising.

When in vulnerable mode, recall is of times that they have been weak, past successes are forgotten. A vulnerable person only counts failures not successes. A positive appraisal of yourself and ability to handle threats gives you self confidence.

The role of skill deficits

A person feels vulnerable if he lacks the skills to deal with a threat. Inceaseing skills decreases vulnerability.

Self-doubt

When the vulnerability mode is active then processing happens in terms of the clients weaknesses. There’s a sense of uncertainty with each act, oh my god, its going to go wrong.

The role of context and experience

As long as  a person has a firm belief in competency he is protected from the sabotage of uncertainty. When we have more skill and experience then we can have more mature and less primal responses. The more skill the more coping resource, the more experience the more coping resource.

There is a strong aspect of context with skill. In private we can play the fiddle, walk a straight line, make people laugh, but do this in public, or walk a straight line over a 100 foot drop. The context provides consequences to failure, and the higher the consequences the more we question our ability and the greater the vulnerability we feel. A more experienced person directs their energy towards problem solving rather than escape behaviours, or protecting himself  in the face of threat. If you enter an evaluative situation then this can increase the likelihood of your vulnerability set being shown, so speaking in private, or speaking in front of a room of people.

Interference with effective performance

A person perceives themselves not to have the skills to manage a threat, they then can actively block themselves from achieving it, eg mind going blank, rigid muscles etc.  A person inhibits themselves in this way as they want to stop themselves going into the danger zone. Thus it becomes self defeating when on one hand your anxious, and your anxiety is trying to stop you doing something and on another hand you’re thinking I shouldn’t be anxious I’m going to do this anyway.

Catastrophic predictions and vicious cycles

As predictions of danger change so does the sense of vulnerability. Walk across a plank 6 inches up and 600 feet up. This can lead to catastrophic predictions when any sign of wobbling can lead to the image of catastrophe, which again makes the levels of anxiety higher, and performance decrease.

The function of dysfunctional behaviours

Physical danger

There is active interference with performance with anxiety which aims to curtail risk taking, and abandon the current plan. The higher the amount of effective danger, i.e. level of danger vs. coping ability plus a factor in of probability, leads to the level of anxiety, which will curtail the action.

The cognitive system evokes caution by putting out thoughts about self-doubt, possible catastrophic outcomes. What the anxiety is trying to do here is to stop what you are doing as doing it more will cause more harm or conceivably if you are under attack stop the body so as it can better respond to a pounding, also there is play dead which is a possible outcome.  So where anxiety becomes an issue is that you want to do the anxiety provoking activity.

Levels of self-confidence in ability to cope lower the levels of anxiety. This is where the a protective person, a helper, I  can’t think of the right word, the human safety blanked  enables anxiety levels to drop and why people cling to people, to raise their self-confidence, lower anxiety. This safety blanket to raise self-confidence, can be seen in social circles by getting people to smile and laugh and therefore like you. That means they are less likely to criticise you.

Anxiety is a primal defence system.

Psychosocial danger

Again as with physical danger, the result of the sum danger level, coping level, and probability=level of anxiety. Here the anxiety makes the problem worse. Anxiety provides physical immobility and inhibits speech. A common social fear is that of showing weakness or impropriety and being devalued. If a person’s self-esteem is tied up with his performance then it can matter greatly to him if he performs badly, so the danger levels are very high. Anxiety says I cannot cope with this danger, so I must be cautious against any slips.  This means increased vigilance, this means selective attention for dangers, never mind looking for safety I must see the dangers that are out there, as I must increase my anxiety levels to stop what’s going on, until I don’t see any more danger and my coping levels feel fine again. So why when you start getting anxiety, does it build up on the basis of your active interference, well you are still active in an anxious making place, you haven’t heeded the warnings so it’s turning up the volume.

The domains of vulnerability

Sectors of the domain

The domains where there is vulnerability are social or personal.

The social domain are those areas where close relationships are vital for success. Thus there is dependency on the other for help and support.  Goals such as intimacy, sharing, understanding, approving and so on. Individuality  are goals that advance a person’s sense of identity, mastery and independence, so these are about status and power, in these instances other people are involved but they are not the goal merely the expedient.

Threats to the domain

Any event that impinges on a domain is either going to be a gain, a maintenance, or a threat. You can also understand the personal and social domains in terms of Public and private.

1.       Sociality

a.       Public sector deals with a person’s strivings in reference to his social group. These strivings include group belonging, support, approval and physical closeness.

b.      Private sector a gratifying relationship with another, intimacy, empathy

2.       Individuality

a.       Private sector: Striving for power, knowledge, wealth, health etc. is similar privately and publically

b.      Public sector: uses others to compare levels of individuality against to measure success levels. Here social roles will be used to succeed, rather than to connect with the group

Threats to sociality

In the public sector threats to sociality are loss of group identity, acceptance and conviviality. So the threats are exclusion and isolation.

In the private sector, then exclusion and isolation are the end game of threat with rejection and disapproval the threat.

Threats to individuality

In the public sector then threats to identity, status or power are threats, which cash out to devaluation, depreciation.  In the private sector then the threats are to health, so disease or death, losing bodily functions, going mad, anything that threatens self-mastery.

Specific fears

If you look at most standard complaints they can be mapped against societal\individual public\private

1.       Panic  attack

a.       Fear of going mad: private individual

2.       Social anxiety

a.       Fear of being judged by the group: public individual

b.      Being rejected by  the group: public societal

Summary

Vulnerability is at the core of anxiety. It says that I am under threat to a danger which I have no power to cope. This inability to cope suggests that with more skills and more experience then there would be a higher ability to cope. Likewise if there are people to support you then this could increase the power to cope. Likewise how significant the danger is will influence the level of vulnerability. If you whole life will be defined by a piano recital then an awful lot is at stake.

Therefore the ways that you can work with anxiety, is to increase coping skills, decrease the sense of danger, also get the client to look at what is causing the anxiety not thinking the anxiety itself is a problem or a sign of something else.

Anxiety then tries to stop reckless behaviour by making you not want to go any further or continue your actions, it can also enable you to ride blows or get the enemy to ignore you by playing dead. These responses are fast and primal

The domains of vulnerability are societal and individual. The former are goals with people the latter are goals by yourself. So the former is acceptance, belonging, intimacy, the goals for the latter are mastery, power and status. You can use the public, private realms to understand most pathologies in terms of individual or societal.

Chapter 6 Generalised anxiety disorder and panic disorder

General View of the Etiology of Anxiety Disorders

The predisposing factors to anxiety disorders are:

1.       Hereditary

2.       Physical diseases

3.       Development traumas

4.       Inadequate coping mechanisms

5.       Cognitive difficulties, unreasonable goals values etc. learnt from others

Three are also precipitating factors

1.       Physical disease

2.       Severe external stress

3.       Chronic external stress

Standardly it is the composition of genetic, developmental, environmental and cognitive that predispose one to anxiety disorders.

Precipitating psychological factors

These are going to be things that increase the danger of an event and decrease coping resources. To increase the danger of an event, it can be an existing event that increased in quantity\quality, or your valuation of that event.

1.       Increase in demands

a.       If a person has increased demands and if those demands are highly related to personal worth, i.e. a vital interest be it individual or societal and there is a depletion of coping resources then anxiety will loom, so promotion, new parent etc.

2.       Increased amount of threat in a life situation

a.       New boss at work, who threatens to fire you, new mother whose baby is susceptible to infection

3.       Stressful events that undermine confidence

a.       Fail at something significant to vital interests that undermines confidence

Interaction of precipitating factors with previous problems

Precipitating factors are only an issue as they highlight vulnerabilities which are a result of the composite of hereditary, physical diseases, development etc.

Do Cognitions cause anxiety disorders

Dysfunctional cognitions are a symptom of depression and anxiety not a cause.

Beck proposes there is an upset in the regulatory functions of the cognitive system that misinterprets dangers. There is usually a self-righting mechanisms amongst emotions. Hostility is usually counter balanced by anxiety. Elation by criticism. So this means that you cant be held in the grip of a single emotion for too long.  What seems to happen with pathology is that the turn off mode has gone, so with anxiety, this would be turned off by seeing that there is no longer any danger. It is possible that some modes become used so often that they prevent the hearing of the usual feedback that would turn them off.

In mania there is an attentional bias to self-inflating ways, in anxiety an attentional bias to danger, these modes are not turned off and then create secondary problems, somatic generally plus also the feeling that this isn’t a mode but this is life.

So the cognitive system actually is the turn off mechanism for anxiety, depression etc. as much as as symptom of them. When the cognitive system starts seeing coping resources, then threat levels reduce and anxiety reduces. When the cognitive system starts seeing achievement then self-esteem increases and depression reduces.  The cognitive bias maintains these maladies either always seeing danger, or always seeing whats wrong with me and the world.

Generalised Anxiety disorder

Symptomatology

The symptoms in anxiety disorders are overactivity of the cognitive, affective and behavioural systems.  An important feature of GAD is an inability to concentrate\mind blurry and fear of being rejected. Also uncontrolled somatic symptoms, shaking, wobbling etc. are prevalent.

Types of Generalised Anxiety Disorder

Two types of GAD:

1.       There has been a traumatic event, this tends to be more acute

2.       An extension of early developmental experiences, this tends to be more chronic.

Acute anxiety state the belief you are actually in a life threatening situation, where the sensation, images etc. are so vivid that you believe you are there. The response system is reflexive and there is hallucination which are responded to.

1.       Traumatic anxiety disorders

The first major class of GAD could be labelled traumatic anxiety disorders, i.e. PTSD. A previous event was so traumatic that it hasn’t been possible to assimilate it, so in some ways its undigested but still in the stomach, an introject that hasn’t circulated into the body but remains awaiting digestion and the message that comes from this process is you cant cope.

The event is traumatic as it highly threatening to something of value and the person felt helpless. Autonomous images: people see images of disasters that creates anxiety, so you have the original event, then separate images that recreate a similar situation. These images are outside volitional control, they can be evoked by certain experiences, or they can come by themselves. Once an image has started it continues until a person is distracted or they go to sleep, it continues or repeats itself, they cannot turn it off. The person re-experiences the original trauma as if it’s in the present. The person cannot see that the image is not the actual event, they quite literally relive their experience

2.       Traumatic psychosocial event, e.g. threat of breakup of relationship, sudden increase in demands of new job, or new parent. This jeopardizes certain values, such as relationship or career success.

On the basis of this there is high anticipatory anxiety and a shutting down of the coping mechanisms which exacerbates the problem. Thus the immediate danger responses then constitute a problem and this is why the anxiety responses escalate, the constant state of anxiety then produce physical symptoms which are then seen as signs that something is really wrong and again there is an escalation.

3.       Chronic anxiety disorder, this is where a legitimate although ungrounded fear is continually worried about, e.g. that I may fail an exam, so I worry before class, during and after. This type of anxiety is often following on the back of a developmental pattern. These patterns are those around societal or individual fears and anxieties. When you have the skills to do something you still don’t lose the fears that you had of not having those skills, weird hunh? When we’re growing up there is both the fear of abandonment from primary care giver and at that transitionary point fear of independent incompetence. The price of autonomy is the decrease of a primary care giver. The fear of disaster combined with a fear of distancing from a caregiver is seen in agoraphobia. There are two modes self-confidence and vulnerability, where each will cancel the other out. Vulnerability was greatest when we were young and self-confidence is greater when we are older. A person fears that they will be ridiculed, they will lose the support of their care-giver, they will not have the competence to reach their needed goals.

Generalised anxiety disorder may derive from a reactivation or extention of developmental fears regarding a persons ability to master new skills and his acceptability to other people.

The difference between GAD and social anxiety is that with the latter there is a skills deficit, but with the former there is an active interference with performance that makes the dangers he fears become more likely.

Specific Fears

There is anticipatory anxiety prior to an event, and retrospective anxiety after an event. Generalized anxiety often have a general fear such as dying, being rejected or attacked, whilst there is no specific situation that cases GAD there are themes that unite the various situations

Social anxiety or interpersonal anxiety appear to be the corner stone of most GAD. The general fear in GAD can also be somatic, so fear of death, madness, etc. The difference between GAD and phobia, is that GAD situations must be attended to, so I want to go out because its fun but I’m terrified I will be rejected whereas with the spider, you just want to avoid it. With phobias I just don’t want to see the spider.

Anxiety can be useful, if you experience it in a social situation, it can be a spur to develop good social skills so you can increase socialization and decrease depression which will occur if you get rebuffed by your social group. Anxiety is therefore a spur to safe behaviour, be it socially or individually. Where anxiety works is where the skills deficit that it shows is remedied, or the dangerous situation is avoided. An immature person will seek instead of making good the deficit take someone or something to lean on.

Loss of control can be an imperative that can cause GAD people are so frightened about it that it creates anxiety.

Proximal fears and ultimate fears

Three types of fear, the first 2 proximal or anticipatory

1.       Fear or a situation

2.       Fear of an unpleasant affect

3.       Fear of the outcome or 1 or 2

Thus there is a proximal fear, the anticipation of being in a situation, the unpleasant situation where you might fear the ultimate fear then the ultimate fear. So your boss calls you into his office, you have fear of having to go into the office of being in the office, and ultimately of being fired, as it is the ultimate fear that colours the other fears.

How this works is that the antciipatory fear of situation can stop you going into the situation, so is preventative.  Children are frightened of the dark, but this is a proximal fear, it’s what might happen in the dark, i.e. be attacked that is their ultimate fear. So fear can keep you away from the bad places, places where bad stuff happens. You may not know what happens in there anymore, because either this is a social truth or you have forgotten, but you know it’s bad. Thus the fact that the situation is understood as dangerous provokes anxiety.

 You get afraid of the anticipation of anxiety. This is when you are in the situation and you are anxious about what may happen. You can be afraid of this anxiety and back away from it.

Finally there is the ultimate fear, here the knowledge of the danger associate with the outcome of risky behaviour is enough to keep the person away from doing it.

The initial physical judgement of the situation is a simple primal judgement and operates quickly but is likely to contain a lot of false alarms.

In a study of 32 people, all were seen to fear psychological or physical harm, but this is self evident, for a patient seeking treatment those do so as they are being harmed! Just before a GAD episode there would be thought such as I’m having a heart attack. Most had a distressing image , prior to attack. Most GAD patients can trace their fears to a speficic incident in their life that frightened them, fear of death\madness\rejection\embarrassment are all the likely candidates.

When someone has PTSD say to being raped, when they experience terror in a similar situation, they do not believe they will be raped there, but that something terrible will follow the terrible, anxious feeling.

GAD with panic attacks is usually around threat of physical problem

GAD without usually psychological problems.

Self-Concept in Generalised anxiety disorders

Concepts of people with GAD are  concerned with inadequacy of personality, or a skills deficit in a particular situation.

People with anxiety problems have problems around vulnerability, this can lead to a shutting down of normal goals which then leads to depression. Vulnerability can focus around some key problem areas:

1.       Confront an authority

2.       Confront a group

3.       Subjection to immediate evaluation of ability

4.       Confrontation with a stranger

In all these situations there is the competence in dealing with a problem and getting respect and acceptance for his individuality and rights as a person.

The GAD client is different from the depressive patient in that he can see the positive aspects of his personality and can separate the consequences of inadequate behaviour from the durable concept of himself.  Self_image of the GAD person is contextual, when in an unthreatening situation they are fine, and contrariwise.

Thus GAD people have different views of themselves, one as competent one as GAD/not competent. Therefore they have multiple senses of self.

Self-Criticism in Anxiety and Depression

Even in anxiety provoking situations e.g. a test, GAD people will criticise themselves for not preparing better, etc.

The depressive criticises themselves in much more global terms, I am a failure, I have always been, the GAD criticises themselves contextually., GAD criticisms produces anxiety as if they were warning themselves of the dire consequences of failure.

The anxious person blames themselves for behavioural flaws, you should have prepared, the depressed person has characterlogical self blame.

People with GAD are often depressed, and people who are depressed are quire often anxious.

The difference between anxiety and depression

The anxious person thinks something will go wrong and they can cope. The depressed person thinks something has gone wrong and it’s my fault as I’m bad.

Depression vs. Anxiety

1.       Depressive criticisms are global I am bad, anxious criticisms are specific, I can’t play tennis

2.       Anxious people see there being a future, they can see their good sides

3.       Anxious person doesn’t see problems as irreversible

4.       Anxious person is tentative in negative evaluation depressed person is absolute

5.       Anxious people anticipate damage to objects, self and relations. Depressed people regrets that he has lost sources of gratification, that he has been deprived of significant other people, that he has been defeated in his objectives and that he is incapable of doing anything to resolve this

6.       Depressed person sees nothing will turn out right for him and he feels regretful and sad, anxious people only predict certain events going badly

Avoidance: depressed people have given up on tasks, routine or otherwise. Anxious people only give up on specific ones. As an anxious persons capacities grow so their avoidance lessens.

Motivation and energy: depressives lack the energy to carry out tasks, where anxiety people have the energy but are inhibited by fear. Anxiety is themed by paralysis, being locked in position.

Depressives lack the energy to carry out tasks, a loss of will power. 

The inhibition of someone suffering from anxiety is lifted on the basis of a change of circumstances, whereas with a depressive person then they have given up on a whole range of objectives before they have event started. So an anxious person’s outlook is contingently troubled whereas the depressed persons is absolute and they expect failure. They feel the failure of the task not yet completed.

The anxious patient is afraid of failure in the future and tries to stop it happening, the depressive sees that it is going to happen. The anxiety patient is not concerned unless a vital interest is threatened.

The anxious person thinks they have something inside them that stops them, they feel a fear for that which will go wrong in the future, whereas a depressed person already feels sadness for the fact that it does go wrong.

Self-concepts. The anxious person thinks they have specific problems, weaknesses, etc., the depressive thinks they have character flaws. The anxious person is contextual,I cant do x at y, whereas the depressed person is absolute I cant do x, period.

Panic disorder

Description

5 aspects of a panic attack

1.       Internal experiences seems strange

2.       Loss of control of cognition, perception, rationality and action

3.       Feels confused and disorientated

4.       Uncontrollable anxiety

5.       Faintness

The most frightening thing about panic disorders is losing control of those things you take for granted, focussing, concentrating, attention, action. It is rare to lose consciousness. There is a dazed and confused feeling that is derealising.  The striking feeling of a panic attack is the feeling of being engulfed by uncontrollable anxiety and the suppression of reasoning power. During the onslaught of symptoms there can be no reasoning that the last time this happened it was innocuous. Whilst cognitive faculties are lost there is still a hypersensitivity to certain noises.  There is also a feeling of weaknesses and fainting. There can be signs of a panic attack such as NATS and inexplicable physiological sensations. Panic attacks seem to signify helplessness in the face of serious danger. The fear of his own vulnerability interacts with psychological and affective responses to produce a vicious cycle.

The panic disorder, has cognitions, I’m going mad, physiological affects that and fear of derangement that almost seem designed to be self-supporting and increase this problem.

The crucial devastating symptom is the inability to control ones mental, physical and affective symptoms, when this happens the client starts to catastrophise.

In simple phobias, i.e. fear of height, animals etc., if escape isn’t possible then a panic attack is possible. Beta blockers reduce tremors and a tight throat but don’t deal with any other symptoms of panic. Valium has an effect on GAD but not on pd. Beta blockers deal more with physiology whereas valium deals with affects.

Meaning of Panic Attacks

A person feels vulnerable backed into a corner and then they take their anxiety reactions as a sign of internal derangement and the real explanation of what is happening.

Panic attacks can be treated with beta blockers. They are a response to an emergency situation whereas anxiety is in response to a danger situation.

Functional Analysis of panic attacks

Primal automatic mechanisms take over in these conditions. They are not volitional, they were designed to cope with physical danger but are now used with psychological danger, and they can actually increase the problem.

Primal physical reaction:

1.       Freezing

a.       to cope with ambiguous danger

2.       Immobility

a.       To prevent falling

3.       Gagging

a.       To prevent obstruction of the airway

4.       Ducking or jumping

a.       To avoid an object

Because these are automatic this creates a psychological danger. These primal reactions often serve no use in mature adults who have better coping strategies, but may provide some use to small children.

Panic attacks differ qualitatively and quantitavely to GAD and anxiety in general. Panic is more intense. In a panic attack you may see depersonalisation, derealisation that you may not in anxiety. You can also see in panic attacks the loss of the ability to reason. Panic suggests an emergency response whereas anxiety suggests a danger response. Panic attacks can be made better by anti-depression drugs but not by anti-anxiety drugs which suggests they are part of a different system.  Whilst panic attacks seem to be spontaneous there seems to be some activation of a person’s alarm system, be it cognitively or physiologically. These can be innocuous but are often accompanied by impaired faculties to reason with himself, be it fatigue or drugs.

Precipitation of panic attacks

Whilst described as spontaneous there seems some experienceses that activate a persons alarm system, feeling faint, or short of breath. These are then misinterpreted. Psychological factors can also precipitate an attack, for instance following the separation with a loved one.

Summary

Generalised anxiety disorders have two forms acute anxiety and chronic.  The former is based in PTSD and has generalised the stimulus. The latter is the result of developmental issues and whilst it will have a theme will be see in a variety of situations.  Actue anxiety there is hallucination and a re-experiencing of the original trauma.

For the GAD sufferer then there are aspects that predispose people to respond in this way, that then make them more susceptible to certain situations, e.g. levels of stress.

GAD is that a situation represents a danger and there’s a feeling of not being able to cope with it and being vulnerable. The vicious cycles of GAD are where the anxiety warning signals are interpreted as a danger themselves and this is where they can escalate.  It seems that the anxiety systems were created predominantly for physical danger but now get used for psychological danger and they actually increase the levels of psychological danger through decreasing its performance. The anxiety systems are primitive and primal and fast.

Within the anxious person then they see themselves as contextually deficient, they can see their good aspects but struggle in certain situations.

For people with anxiety disorders then there is a problem with turning off the alarm system when the danger has gone, it is as if the alarm has been working so often that its got stuck

The difference between GAD and panic attacks, are the former are for danger the latter for emergency. You can see this as GAD and anti depressents work and panic attacks and beta blockers work but not vice versa. 

The anxiety system are from a primal response to a danger, there is a good chance that they were created in response to physical danger but now are in response to psychological danger so are not adaptive.

The vicious cycle of anxiety is when the symptoms of anxiety are seen as a problem, oops I said this above, oh must be getting tired.  Anything more to say about GAD, no but the clients that I have worked with have more complained about excessive rumination, which whilst part of GAD doesn’t really do it justice. GAD is where there is anxiety in numerous situations, rumination in numerous situations is different. Now admittedly there might be anxiety that the rumination is seeking to reduce, but that is the step that you need to take or be clear about.

Chapter 7 Simple phobias

Definition of Phobia

Phobia derives from the Greek Phobos which means flight, panic-fear, terror and comes from the Greek god Phobos who could invoke fear and panic is others. The sufferer of a phobia doesn’t accept the grounds of their fear as reasonable.

A person facing their phobic object has a degree of anxiety, and has what is akin to a medical emergency, pounding heart. The second powerful urge is to escape or avoid contact with the object or situation of fear. The third characteristic is that outside of the interaction with the phobic object he sees his fears as exaggerated or ungrounded but despite this realization it doesn’t change his reactions to it. A phobia magnifies a fear. A phobic has anticipatory anxiety when he thinks he is going to meet his phobic object, this is the same anxiety as can be seen in GAD.

The objects of phobias are objects that normal people fear too, or archaically feared and the phobic merely magnifies this level of fear, and the magnification of risk.

A phobic, who has anticipatory anxiety of encountering their feared object, has similar symptoms with someone who has GAD. In fact what is the difference, someone who had an acute trauma, will have GAD by generalising the original trauma. Someone who has chronic GAD and who has developed with a feeling that they won’t be able to cope and some things are very important to their being. So I guess the difference is in terms of values GAD people have something they value threatened and they don’t know how to defend against it, a phobic merely fears the object, they don’t threaten directly a value object, such as self-esteem, but rather the spider that will bite, or the birds that will touch me, I guess the valued object is their health which with downward arrow would probably show.

Differentiating phobias from fears

The difference between phobia and fear is the reasonable factor, if generally people think someone’s fear is unrealistic, over emphasising the danger, and the risk then it’s a phobia. So it’s a social construct.

A person with a specific phobia, isn’t weaker on the sensitive scale as often they can tolerate other situations that other people are highly afraid of. 

The refractoriness of phobias

You can’t change a phobia by educating the person about the feared object.  Intelligence or realising that a phobia is unreasonable doesn’t diminish it, indeed phobics can be powerful people in all other areas, Often the reason for the phobias development is unclear. From a distance a phobic has a greater rational appraisal of the situation, but closer this rationality goes.

Content of fears and phobias

Phobic objects have changed, gone are the fear of Satan, but up comes the fear of radiation. The fears of phobics generally tracks the fears of non phobics, just exaggerates the risk.

Phobias spread associatively, knocked over by a truck when working, then get fear of working in road, then fear of driving on road. The link is a similarity in type of danger.

There is rationality for the phobic about their fear, but there is a chance that it has been being done for so long they have forgotten what it is and merely act now on the basis of intuition.

Classification

Phobias can spread through a process of abstraction in a similar fashion to OCD. However in phobia it is similar in type of danger, in OCD then it can be other forms of relation, i.e. spatial, can’t touch the handle, can’t touch the cloth that could have been placed on the handle, hmm, that’s similar to the same type of danger. Maybe they are the same.

There are three major types of simple phobia:

1.       Social rejection

2.       Agoraphobia content, e.g. travelling alone, being in crowded places, heights

3.       Being cut or observing bleeding

Traumatic phobias

Phobias often develop from a traumatic experience or a childhood fixation, also continued exposure to danger can do it. People with a traumatic phobia are often able to date the onset of their phobia to the event that started it.

Fixation phobias

Common in childhood, e.g. fear of water, thunderstorms, blood, doctors etc. Children have a lot of fears, and young children it focuses on physical harm, and older children it focuses on psychosocial harm. Most children outgrow these phobias but why don’t all of them? It is possible that these are carried into adult hood as the child watches their parent’s avoidant behaviour and copies it, or avoidant behaviour was reinforced by parents. Alternatively there might have been an incident whilst the fear was active, that created the avoidant behaviour.

Specific phobias

1.       Acrophobia is fear of heights.

a.       The sufferer can get somatic images where they feel the fall, imagine the fall and this creates dizziness. The sufferer thinks either they might jump from the height or that some external force will pull them over the edge.

2.       Elevator fear is that the elevator will drop or stop between floors.

a.       There can be those with this fear that have a physical fear that they will go crazy or a social fear that they will faint and then suffer embarrassment afterwards

3.       Claustrophobics, believe the walls will collapse and they will be trapped, buried alive.

a.       They fear that they will suffocate due to insufficient air, or be buried alive

4.       Air plane phobics believe they may lose control due to tension in the plane, that they will run out of air, due to the planes air con not working, oh yeah and the plane crashing.

a.       There is a a social fear going on, that they will faint and be an embarrassment. There can also be a fear similar to agoraphobia that there is separation from a caregiver who can help them if they have a heart attack

5.       Blood phobias, they get squeamish at the sight of blood, it’s not a fear but rather it creates a collapse response

a.       People phobic of blood usually have other phobias and fears., the common denominator is passivity and a sense of helplessness in the face of possible injury.

The Meaning of Phobias

Phobics who fear the same object, may well fear different consequences. So same phobia different fear. They may well have the same fear to different objects or events.

In general phobias tend to focus on:

1.       Physical harm

2.       Natural disaster

3.       Social embarrassment

Multiple phobias: Conceptual continuity

Many phobics have multiple phobias. Standardly with multiple phobias there is a common link between them.

Relation of fears to Phobias

Sometimes difficult to tell the difference between fears and phobias, as phobias always have a grain of truth within them.  On the spectrum between fear and phobia is phobia, standard fear, then counterphobia, where people do objectively fearful jobs with no fear, e.g. soldier, tanker driver

Self-Confidence versus vulnerability

Why do some people have no fear when they should do? The more often you do something dangerous the less anxiety you feel, e.g. driving a petrol tanker.  It is possible through repetition of the feared activity you see that your worst fears will not be realised.

Dual belief System

Phobics have a dual belief system, one belief in the phobic situation one outside, one believes the phobia, one doesn’t.  As much as you can have cognitive fantasies, i.e. rumination, you can also have visual fantasies.  When not near the feared situation they have a standard objective probability of disaster, as they get closer to this, this changes due to activation of cognitive distortions and visual images, and they have a high probability of something very improbable happening. You’d wonder if the warning signs that get created, e.g. visual distortions and somatic responses, actually recreate the same situation as if there was danger,

Visual Images

Some people have acute visual images that create anxiety, they seem to operate as a warning sign for an impending doom.

Identification with Victim

Some phobias happen by watching someone else in a dangerous situation, e.g. hospital staff watching an operation. This happens through an identification with the patient.

Evolution, Rules and Phobias

The rules for promoting immediate survival against an immediate threat are fast rules, i.e. global, absolute, there is no question or ambiguity. The rule is applied on the basis of a part object if it is that terrifying, so the eyes of a hawk, for a mouse. It is good for children to use absolute rules until they become mature enough to refine their rules. Pre verbal rules are often in terms of images and conveyed by the expression of the mother. The movement from an immature rule to a mature one is the realising that the rule is too absolutist or that the fear is exaggerated most of the time. Immature fears are not entirely got rid of, and when we are stressed, tired etc., they can reappear, or maybe depression.

There’s seems to be some evolutionary benefit to these phobias, fear of small animals, heights, open spaces. Whilst absolute fears will generate many false positives again it seems that evolution favours the nervous.

Summary

Phobias are an unreasonable fear of something. The root of them is within either current or historic fears in society or in childhood and are magnified.  They have the form of being an absolute rule about their fear, which is on the basis of a part object and in no way allows proability to come in to their equation, in this way a phobic response is like the response to an immediate threat.  The base fears in phobia are:

1.       Physical harm

2.       Social embarrassment

3.       Natural disaster

Standardly a phobic has a dual belief system, one when distant from their feared object and one when close. The movement between near and far is represented by an increase in the danger signs system, i.e. distorted cognitions, visual images etc.

There is a spectrum from phobia on one side, normal response to counter-phobic, where people do dangerous jobs with no fear.

Phobias can be things that started in childhood, or from a trauma and then fixated at that point. They are also things that can be more prevalent under times of stress, depression etc.

Chapter 8 The Agoraphobia Syndrome

The Riddle of Agoraphobia

Why does a person develop agoraphobia in their 20’s when they have no other psychiatric problems?

The Development of Agoraphobia

Predisposition and precipitation

Agoraphobia occurs after the age of 20. They say that agoraphobics have panic attacks with regards to separation and that they have had a lifelong fear of the ability to cope and that there has been a protective figure there who makes it alright. So mum and dad and at the age of 20 then they are separated from them agoraphobia can be brought on as the needs to be more adult increase or the protection and coping mechanisms decrease, e.g. death of a care giver, or birth of a child. There is also the sense that if the client performs inadequately there will be disastrous consequences. In a typical scenario then the client sees the person who supports them is also suppressing them, then as demands increase there can be a reversion to an earlier dependent state.

Onset of symptomatology

The fears of the agoraphobic are losing control, getting lost, being bowled over and it seems like the salient aspect is not being able to get back to the caregiver, get back home. These seem similar to the fears of a young child.

Aspects of agoraphobia:

1.       Perception of unlimited opportunities to be humiliated, crushed, attacked etc. and no reliable defence against these threats

2.       Reflex produces panic physiology which is suggestive of serious internal problem from which there is no escape

3.       Experience of malfunctioning and a decrease of competence

4.       Loss of control over reactions, noticing that they have no control over the external threat or in response to this the internal threat, i.e. diminishing of functioning, and panic physiology

5.       Loss of sense of competence, fears of internal and external disturbance means seeking assistance from the care giver

6.       Home or safe haven is safety from external threat, internal threat caused by external

7.       Multiple inhibitions, submissive tendencies and negative appraisal of self, undermine self-confidence and thus tend to disequilibrium in relationships thus feeling dominated by other people

Panic

Attribution of causality in panic attacks

Some people believe that agoraphobia begins with clients with a panic attack.  Some people have agoraphobia without panic, some have agoraphobia and then panic. In many cases the progression to panic attacks follows a period of tension where a person can’t deal with a novel problem.  Without coping strategies there builds up a sense of hopelessness and various somatic and psychological symptoms. Rather than link this sense of unease to the novel problem it becomes linked with a problematic internal state. You can also sometimes see the preponderance for explanations that people have. If symptoms are unexplained then it could be that people revert to their default explanation of problems, such as a disease or a character defect.

Imagery plays a role in agoraphobia, where people imagine malign events in public places. The panic attacks in agoraphobia are the same as with GAD, some patients can head off a full blown attack by distraction, cognitive restructuring, or seeing the symptoms as an emotional reaction not the sign of a catastrophe.

Cognitive set: vulnerability

As a client approaches a phobic situation she locks into a vulnerability set. Before the situation they are worried about an uncontrollable reaction but they don’t see it as indicative of anything serious but inside it they do.

The base cognition seems to be that when you are alone you are vulnerable, this can be assuaged by somewhere or someone safe. So they can have a minor complaint, can’t get to safety, this increases fear of not being able to cope which intensifies the sensations which leads to feeling that something serious is happening and they can’t cope. If they can’t get to a place of safety or a caregiver then this sense of danger radically increases. Again the danger signals suffered, give indication of the seriousness, and the immediacy of the danger.

The agoraphobic operates on the following principles

1.       An overwhelming danger can occur

2.       There’s nothing I can do about this

3.       If I can get to a place of safety, or a caregiver then I will be ok

4.       Any particular sensation can be a sign of this

5.       If I don’t stop this danger, or sensation then it will increase into ultimate disaster

Specific locations cause problems as they block access to safe havens and caregivers, the key feature in all of this is the sense of being trapped. They can also be seen as having an element of danger it, that is why they are so toxic, as they are dangerous and block access to safety. There can be a whole host of dangers getting to the phobic place, e.g. driving to the mall, the mall is the phobic place, but there are phobic dangers attached to the drive too.

Opticokinetic reflex: where the geometry of a building can both suggest being hemmed in and being engulfed by too much space, so can’t get back to care giver.

Agoraphobics value mobility and means of getting to safety, paradoxically one of the responses to this is immobility. Mobility is however a need on its own and freedom, self-determination and individuality are all aspects of it, and remind me about the feeling suppressed by the care giver. There are often fantasies about being completely free, breaking loose from conventional rules of behaviour by yelling, acting crazy doing destructive acts. The conflict then is around on one hand dependency and need to get to safety which mobility forms a part of and also a  resentment of this and a need to feel free. Thus they feel incapable of coping without the support but rue the loss of freedom that is associated with this. This is important an agoraphobic not only needs to escape the danger, but also they have a need for complete untrammelled freedom. They need the caregiver but there is also a resentment of this, possibly shown by the need for ultimate freedom. Thus the issues revolve around danger, dependency, autonomy and control.

An agoraphobic has

1.       A strong emphasis on self determination

2.       A hypersensitivity to control or interference

3.       A tendency to react to threat with weakness or escape

4.       A tendency to react to somatic complaints as a sign of physical disruption

5.       A strategy of depending on a caregiver or a safe place

An agoraphobic doesn’t want to be too close to their care giver lest they get dominated nor too far lest they can’t cope, this is mirrored in their relation to space where they don’t like things too narrow, too close, nor to expansive.

A Synthesis

The following is a synthesis of the above material and is based on clinical observation

1.       Agoraphobics have fears that were realities in early childhood but not in adulthood. Susceptibility to these fears is increased when under stress.

2.       With the background of reduced internal and external resources the fear of being away from a safe haven may be activated due to trauma

3.       A panic attack is taken as a sign of some internal disorder, the patients reduction in cognitive faculties means that they cant objectively  assess the danger.

4.       The reduction of faculties, and the increase of danger means search for a caretaker, who is seen as having faculties not impaired. The caretaker is there to get the person to a hospital if there is a physical danger or to reality test as they have lost their faculties

5.       There are a number of circumstances that can be interpreted as dangerous

a.       Places where panic attacks have occurred

b.      Places which are relevant to latent fears from childhood

c.       Experience of dramatic internal states

d.      Separation from caregiver or safe place

6.       Hypersensitivity to too narrow or too expansive places

Summary

Agoraphobia generally has an onset in the twenties. This can be a time when they have less support from their parents. It can be that there are childhood fears of being abandoned or of being overwhelmed that have both been supported and created by their parents. When they no longer have this support or there is a critical incident you can see the onset of agoraphobia. Agoraphobia can extend from a specific type of place to other places.

What you see in agoraphobia is a panic attack when they can’t get access to their safe place or person. This comes from a feeling of vulnerability in not being able to cope with danger. When a panic attack comes from a dangerous place then cognition is impaired, somatic symptoms show danger and there is a sense of high scale impairment of faculties that needs to access the faculties of a caregiver to ensure there is safety from danger.  Mixed in with this is a resentment of the dominance of the other and a desire for complete freedom.

The agoraphobic is hypersensitive to internal signals of impending disaster

Chapter 9 The Evaluation Anxieties

The Essence of Evaluation Anxieties

Before the fall

A person with social anxiety feels vulnerable unless his performance is adequate. An adequate performance is according to certain rules and procedures. The greater his confidence the greater the skill, if he has a failure then he may have a primitive motor response. Social anxiety is a test of maturity and ability. Smooth performance maintains his image and his status and contrariwise. His performance is judged by everyone there, a crowd of evaluators who appraise his performance as clumsy or skilful.  Thus whilst his actions represent a small fraction of his interactions he fears he will be judged on these and the damage is to the entire person.

There is the sense of a tightrope walked an error would result in a fall from grace, watched by observers, the reaction to falling off the rope would be shame and humiliation.

Common features of evaluative threats

The evaluative anxieties are:

1.       Social

2.       Performance e.g.  exam etc.

3.       Transactions with outside word, e.g. shopping, buses and engaging with the functionaries

The modulators of situation are

1.       The relative status of the client and his evaluators

2.       The clients ability to produce a front

3.       His confidence in performing adequately

4.       His appraisal of the degree of threat and the level of its consequences

5.       The threshold of his automatic defences and how likely they are to be activated. These automatic defences, such as speech inhibition or shaking, suppression of spontaneity, will weaken performance

6.       The anticipated punitiveness of the evaluators

Vulnerability

A client then has a number of questions to ascertain his level of vulnerability

1.       How much do I need to prove myself to others

2.       What is my relative status to my evaluators

3.       How important is my relative status to my evaluators

4.       What is the attitude of my evaluators

5.       To what degree can I count on my skills

Status and ranking order

A good part of the pressure to perform is related to the relative position on a vertical scale of power or social desirability. If a person appears self-confident then this can induce feelings of inferiority. The higher the status of the evaluator, the lower the status of the person, and the more inferior they feel. Likewise the more dominant the evaluator then the more submissive the person can respond.

Self-confidence can be knocked by valuing the evaluator and him lower, seeing a lot being at stake on this. As self-confidence goes up vulnerability goes down and vice versa.

Thus a person’s self-identity and value is concerned with their performance which is gauged in accordance to others. Their self-confidence is then affected when they are with high status people. Their response maybe avoidance of situations where this may be encountered which then leaves them with a feeling of low status.

Self confidence

Confidence then is related to the levels of perceived skill, the threat of the other and the levels of danger which result in failure.  There is a reciprocal relationship between confidence and vulnerability.

Rules and formulas

As performance is key to evaluation and status then there is a set of rules that need to be obeyed to get points.  Failure to keep to these rules increases anxiety, lowers confidence, increases vulnerability and effects performance.  Feeling that rules have been broken then increases a sense that there will be rejection.

Automatic protective reactions

Automatic Reactions

A person under threat of evaluation may evoke automatic reactions which whilst anachronistically useful as they may protect against attack, serve no current useful purpose, they can be to impede the flow of speech, thinking and recall.

Anxiety

This becomes a spur to reduce the sense of danger. This might be to escape the situation, to being inconspicuous. Again the need for safety that anxiety can bring impacts on performance and brings a negative spiral.

Faint

Again people fear, or have this reaction. Evolutionary this might have been appropriate when there is the fear of imminent attack and that playing dead may be the way to survive. But it is dysfunctional and increases the problem

Social phobias and social anxieties

Social phobia and social anxiety clients have an exaggerated feeling of being the focus of attention. Whilst most people have some levels of social anxiety, the pathology is where a person’s normal activities are restricted.

Paradoxes of Social anxiety

Social anxiety\phobia has a reality factor that agoraphobia doesn’t, thus they may fear their mind going blank and being tongue tied and it can happen, indeed their fears seem to increase the possibility. The person with fear though thinks that inadequate performance will be a mortal blow to his social aspirations.

The fear of being evaluated

Social anxiety is the fear of having ones weaknesses exposed, being shown to be of low status. A social situation for one with anxiety is a situation in which he is being judged and will be hypersensitive to signs of being judged. There is also a fear of being the centre of attention, where he fears he is being judged and scrutinized.

The agoraphobic is hypersensitive to internal signs that there is impending disaster the social anxiety client is hypersensitive to external signs from the other.

The primal defences

The biggest inhibitor to social anxiety is not the feeling of anxiety per se but rather the primal responses of verbal fluency, thinking, recall and memory. This is a freezing response that prepares the individual for physical assault.  The freeze response gives you time to evaluate the situation and prepare your response, it also prepares you for physical assault so you can ride the blows but it inhibits social performance.

Differentiating Social Phobia from Agoraphobia

Situations that provoke the phobic symptoms

Symptoms more viewable in social phobia, but fainting more common in agoraphobia. Social phobia is concerned with inter personal situations and of being scrutinized by other people.  Agoraphobia is about being vulnerable and not being able to cope. The social phobic represents the child being scrutinized by adults, whereas the agoraphobic is the child who has been place in a strange place for the first time. Social phobics are a small child being judged, agoraphobics are a small child being ignored. Agoraphobics more often have cluster of fears around physicality. Agoraphobics tend to have collapse response where social phobics tend to have freeze responses. Agoraphobics can also have a fear of being alone, where the social phobic is happier in this space. The agoraphobic has higher levels of comorbidity than the social phobic. The common occurring problems with the agoraphobic are other sorts of phobia. The clustering of the agoraphobic suggests the fear of being attacked i.e. they are frightened of some physical attack or damage.

Somatic symptoms

Agoraphobics tend to have a collapse response, whereas social anxiety people tend to have a freeze response.

The phenomena of Social Anxiety

Features of social anxiety

1.       Perceive criticism from others

2.       Expect criticism from others (anticipatory anxiety)

3.       Feeling less capable than others, low self esteem

4.       Have rigid rules for social behaviour and being inflexible

5.       Negative fantasy which produces anticipatory anxiety

6.       A sense of being watched waiting for the judgement

7.       Hypervigilant of any sign of being judged by the other

8.       A sense of being trapped in a situation

9.       Hypervigilant of bodily signs of social unease

10.   Fear of losing control

11.   A fear of situations where a sudden and unexpected withdrawal would be likely to attract attention

12.   A sense of being trapped in a social situation

13.   A build up of uncomfortable feelings

14.   The unpredictability of the anxiety response, the mood of the day and the amount of time available for negative fantasy seem to have a determining influence on this.

Social anxiety often starts around the late teens

Shame and social image

Shame is the feared emotions in the social situation. Shame the feeling that you are judged to be weak, inept etc. in the eyes of others, and you don’t want to be.  It’s the feeling of having your weakness exposed and judged. What is critical is that the other thinks their judgement of your weakness they don’t have to express it. It is questionable whether the client believes this or not, the chances are that they do believe it and fear the ridicule and devaluation.

A person with social anxiety, has a shame reaction, to believing other people have thoughts of negative judgements about him. However in private, or if he thinks he has got away with it, he is fine.

The public sanctions for lack of conformity make the social anxiety client feel weak, inferior, depreciated and immature.  They are shame, ridicule and isolation. He believes he will be subjected to public humiliation and ridicule and he will be powerless to defend against it. Social opinion is absolute, final and irrevocable. The only antidote for shame is to vanish from the situation, whereas with anxiety in general there is the desire of flight to safety.

Social group have surface and deep values, surface may be rules of engagement, public rewards are given of admiration or punishments of disdain, ridicule or isolation. Any person in the group is representative of the whole group, so if you fuck up with one person, you fuck up with all. Strangers can create more shame than can intimates. Shame is a form of social influence where people try to control our behaviour through it.

Shame and anxiety differ in that shame lasts after the shameful experience whereas anxiety doesn’t. Shame is a personality judgement, anxiety is a fear response.

Intimate relationships satisfies personal needs whereas public relationships satisfies public image. In personal relations then the expectations are of understanding, caring and consideration and the punishments are removal of affection or rejection. The effect of personal punishment is sadness.  Qualities valued in intimate relations kindness, empathy and warmth are often understood as character traits.

Things admired a group are appearance and performance. In intimate relationships there is less concern about group norms. It seems that strangers can produce shame reactions where intimates can’t. The stranger becomes representative of the social group, where the isn’t.

Fear of loss or love or abandonment

In personal relationships there is more a requirement of satisfying certain functions rather than conforming to a certain image. In the personal relationship the requirements are understanding, caring and consideration. The punishment for a failing in personal relationship is rejection of the withdrawal of affection, the resulting emotion being sadness. The functions of personal relationship, i.e. caring, warmth and empathy are more seen as character traits, whereas in public relationships its more concerned with performance. You can get social anxiety in the private arena where there is the threat of the loss of love, where you need to perform to a certain level to achieve love. The effect of this is

1.       A sense of vulnerability

2.       Feeling always judged

3.       Stilted behaviour

4.       Catastrophising about the future.

Public speaking anxiety

The anxiety here is around not being able to control oneself which means you have no control over your mind or your body, which is a primal survival threat. There is fear of not being able to function and fear of being judged by the audience. Anxiety relates to threat. Anxiety is a feeling we want to stop, anxiety might stop us in our tracks so we can judge a situation, anxiety might make us stop so we can survive. The trouble is when the warning system gets taken as something to be scared of, or to represent something to be scared of. The speaker then reacts to a perceived but unreal enemy that brings about what he most fears, not being able to perform.

The biggest fear is not being able to function and that this will be judged by others as sign of weakness. The anxiety reaction is then interpreted as a sign that one is not functioning well and thus you get a negative spiral. Likewise negative response from the audience will create a negative spiral, or non positive can do the same.  The negative spiral leads to a barrage of negative thoughts,

The cognitive set is that the audience are perceived as threatening. There is a feeling of incompetence. He believes any deviation from the rules will elicit a negative response. He believes he is incapable of dealing with a negative response from the audience, and he will be open to ridicule and criticism. The cognitive set prepares himself for danger of a foe, the audience that is far stronger than him and is poised to attack him or reject him. Under the influence of this fear he reacts with a primal response of freezing and what he most wants to happen, to give a fluid presentation and for the audience to love him becomes far harder to achieve.

Test anxiety

Some time from the exam the student may well feel confident and well prepared, but as the test looms, then the confidence drops as cognitions centre around the disaster of failing and its likelihood. Once the vulnerability set is started, then anxiety increases and self confidence decreases and at the exam, then the primal response to danger, freezing is evoked, and his mind goes blank. When the mind goes blank, it could be that it feels overwhelmed so like with the electricity company shuts down the non important, it could also be that it is a primal response to divert all energy to the danger. Some students pass from the freeze phase to the fainting phase.

A Synthesis

To the sensitive subject being evaluated is similar to be subjected to a painful probe. He assumes that evaluators’ jobs is to expose his presumed weakness and his job is to conceal them. To this situation then he stiffens becomes less spontaneous acts to some rigid rules and presumes every slip will be pounced on and will have a long range negative effect.

As part of self protection as they feel vulnerable then they retreat into themselves to protect their soft shell. In other words they are inhibited.

Summary

The evaluative anxieties consist of social anxiety, test anxiety and public speaking. Here the client sees themselves as being judged for their performance by evaluators. The thing that they fear is the shame and ridicule for having their weaknesses exposed. The shame that they suffer lasts longer than anxiety which goes when the object that arouses anxiety is not there. Feeling shame then there can be avoidance of social situations and can leave the client feeling inferior.

If the evaluators are higher status than the client, or the outcomes of bad performance are seen to be high, or the evaluators are seen to be hostile then this increases the levels of vulnerability. The client sees they have nothing that they can do to counter negative criticism or rejection. The effect of all of this is freezing where cognitions all turn to aspects of vulnerability. The constant streams of negative thoughts mean that the amount of available cognitions is minimal and cognitive faculties are greatly impaired. This can mean that the mind can go blank.  Likewise speech can be inhibited and stuttering can be seen. What is happening here is a primal response to the feeling of danger and of vulnerability. What the freezing looks to do is respond to a physical threat and buys time to make the right decision and to be able to withstand blows should an attack be occurring.

With social anxiety there is a reality that you can be rejected, judged or make a fool of yourself. However when you make you social identity a key aspect to your identity and that equate that with performance then the anxiety becomes self defeating as it makes you harder to achieve your goals, so it is something of a paradox. Again the only explanation for this can be that a primal response that has been created to deal with a physical threat is applied to a psychological threat.

Social anxiety is generally only found in the public arena, in the private arena, with intimate people, family and partners then you don’t find as much social anxiety as the nature of the relationship is more based on functions where there is a requirement to show understanding, care and empathy. Performance anxiety can be found in this space, when a partner has demands and threatens the removal of love on the basis of an inadequate performance.

Chapter 10 Principles of Cognitive Therapy

There are ten prinicples of cognitive therapy

1.       Cognitive therapy is based on the cognitive model of emotional disorder

2.       Cognitive therapy is brief

3.       A sound therapeutic relationship is needed

4.       Therapy is collaborative

5.        Between patient and therapist

6.       Cognitive therapy primarily uses the socratic method

7.       Cognitive therapy is structured and directive

8.       Cognitive therapy is problem oridentated

9.       Theory and technique of cognitive therapy rely on the inductive method

10.   Homework is a central feature of cognitive therapy

Principle 1: Cognitive therapy is based on the cognitive model of emotional disorders

a.       Dysfunctional appraisals of the situation maintain anxiety.  Anxiety can be a result of exaggerated and automatic thinking.

b.      Sympathetic nervous system is the fight or flight , parasympathetic is the rest and digest system

c.       Anxiety is related to prior appraisal, i.e. you aren’t afraid of a poisonous plant until you have learnt that it is poisonous.

d.      What is feared is the feelings and the sensations

                                                               i.      Primary fear is fear of disease, fear of going mad

                                                             ii.      Secondary fear is the fear of the feelings of anxiety which may indicate going mad etc.

e.      Four basic emotional states, scared, mad, sad and glad

f.        Clients problems fall into four categories, anger, depression, anxiety and pleasure(not getting enough I guess)

Didactic Presentation

Working with clients then anxiety can be presented as a natural reaction to fear.  Its propensity can be created through developmental issues and its maintenance can often be via dysfunctional thoughts. It can also be that the anxiety system can itself be seen as something that can be seen to be dangerous and when this happens then there is a painful and anxious cycle that is created.  On the basis of anxiety there is a need to reduce this feeling and this can happen through fight, flight, freeze or faint.

Levels of fear

In anxiety disorders there are two levels of fear. One is fear of danger physical danger, the second is the fear of social danger, what is really feared is the feeling of anxiety and its concomitant symptoms; the negative thoughts, the cognitive inhibition, the physical inhibitions. So what happens is fear of the actual danger produces anxiety then fear of anxiety creates an anxiety spiral.

Principle 2: Cognitive therapy is Brief and time limited

Brief therapy means there is no dependency created with the therapist, and therefore is more empowering to the client.

Brief therapy:

1.       Stays task focussed

2.       Focus on manageable problems

3.       Make treatment specific and concrete

a.       On homework

b.      On interventions

c.       With conceptualisation

d.      With language with the client

4.       Use homework

a.       This will increase the amount of result that you can get

5.       Uses time management techniques

a.       Set agenda

b.      Give handouts

c.       Give homework

d.      Get the client to prepare what they want to talk about

6.       Keeps it simple

a.       Complicating a problem slows down any action taken on the basis of it

Principle 3: A sound therapeutic relationship is necessary condition for effective cognitive therapy

A sound therapeutic relationship is needed:

1.       For someone to face their fears, for someone to deal with difficult feelings they need to be with someone who they trust and feel safe with

a.       This can be a major part of the work, where they can face their fears with their therapist, means that they learn to face their fears

b.      To build trust use sincerity, empathy and non dependent warmness

2.       Patients have style, some prefer more formality, some more casual

3.       You can quite often map people on the autonomy, dependence axis.

a.       Low dependency, low autonomy means capable of managing intimacy and forming a good working relationship

b.      Highly dependent, low autonomy means a patient is more relationship orientated. Patient can be highly sensitive to a lack of empathy and can become dependent, so these features should make you adjust your interventions. A therapist has to be warmer in such situations as this will give the sense of a close relationship which will suit the client. Such a client often wants to be the favourite client. Self-disclosure good in this instance to increase the strength of the relationship.

c.       High autonomy and not dependent, would react badly to how do we solve this problem as that would be patronising as he is more than capable, self-disclosure would be bad, again let these ideas influence your interventions. Best interventions start how are you, what are you, stressing the independence of the client via you

d.      High autonomy and highly dependent can be really awkward clients; someone who wants to be independent but really needs people but conceivably fears them. Wants intimacy and has trouble tolerating it.  In this instance tolerance, flexibility and acceptance are going to be helpful.

Principle 4: Therapy is a collaborative effort between therapist and patient

Therapy is collaborative

1.       Two heads are better than one

2.       There are four selves, the thinking, emotional , acting and observing self

As the therapist collaborates with the client then the collaboration needs to be with the clients adult, how are we going to solve this problem? The therapist also collaborates with the observing self, when there is collaboration with the clients observing self then more information about how the problem is manifest and therefore what can be done about it is made manifest. The greater ones awareness, the greater the choices that you can make, the more you know yourself.

How to collaborate

1.       Have a reciporocal relationship where no one takes a superior role

2.       Be transparent, avoid hidden agendas, so always explain the rationale for homework, or for formulation, and indeed sometimes even for intervention

3.       Design homework collaboratively

4.       Admit Mistakes

a.       A coping model is usually more effective than a mastery model

Principle 5: Cognitive therapy uses primarily the Socratic Method

Socratic questions:

1.       Questions can help the patient see coping mechanisms as these are the questions that they should be asking

Principle 6: Cognitive therapy is structured and directive

An anxious person may lack structure that therapy can give, for their disorder you can give some order in the session. So let session structure reflect the desires that the client has. You need to alter the level of structure dependent on the person. A socially dependent person usually prefers more structure

1.       How to structure

a.       Set an agenda of problems to be looked at, client starts, usually only 2-3 issues can be dealt with effectively

b.      Choose a target problem

                                                               i.      First go for symptom relief

                                                             ii.      The teach how to recognised distorted thinking

                                                            iii.      How to respond to distorted thinking

                                                           iv.      Identify and modify underlying assumptions that produces NATS

c.       If a client is tangential, then look for common denominators, this simplifies the problem and gives it structure            

d.      Test that you are getting there: am I on the right track  

Principle 7: Cognitive therapy is problem oriented

Its easier to change the current problems, rather than past things that have happened, or the future, indeed you could argue that you can only change current problems.

Problem solving Best Practice:

1.       Avoid problems that cant get closure during a session(?)

2.       Problem solving format

                                                               i.      Conceptualise

                                                             ii.      Choose a strategy

                                                            iii.      Choose techniques and tactics

                                                           iv.      Assess

Conceptualisation

Conceptualisation is possibly the most important part of therapy as it maps out the various aspects of the problem and what maintains it. It also provides targets for what to do. So knowing how thoughts affect feelings and behaviour, shows the type of interventions that can be made.

Conceptualisation shows how a problem originated and how it is maintained. It attempts to understand what the problem means to the client and therefore why they behave in the way that they do.

General strategies

Problem solving best practice

1.       Simplify, e.g. when anxious take constructive action

2.       No time like the present. Things that come up in the present have most potency, so in vivo, in session are the best.

3.       You don’t know unless you try

a.       What will you learn\get through trying, and what will you learn get through not trying

4.       When the therapist is off track take the opposite track

a.       So if a client is afraid of cancer, then imagine what if you had it

b.      If you can’t change a situation try accepting it

5.       Patient persistence

a.       Therapists model patience to allow the client to do the same. So if you don’t get results first off, then stay with it

6.       Divide and conquer

a.       Focus on the part of the problem with the least resistance to get some wins and some change. If you have a behavioural problem, then focus on thoughts and feelings, if you have a thinking problem then focus on behaviours and feelings

b.      Anxiety is made up of three aspects, thoughts, feelings and behaviours, best work is to work with the aspect that is most modifiable, so anxiety being a feeling problem then work on the thoughts and behaviours.

7.       Do the unexpected

a.       Change requires doing something different and surprising yourself, so if you’re stuck then do something different

8.       Go with the flow

a.       Find out the place where a client’s formulation of anxiety is weakest and target that

b.      When the client is highly defended then use a metaphoric approach

9.       Find the resistance and work with that, work with how the client presents and roll with the resistance

Principle 8: Cognitive therapy is based on an educational model

Premise that anxiety is learned behaviour and so can be unlearned. People use repeatedly problematic solutions to problems, they give prophecies to justify their problems and they manipulate the world to make their problems come true. They reduce their domain to fit their image

Learning to learn

You both need to learn coping techniques and more importantly learning to learn, as the latter makes you flexible to whatever happens to you. The neurotic paradox is where you repeat damaging behaviours and fail to learn

People often have some hard core beliefs and a defensive belt around them. I guess he aim then is to loosen the defensive belt, which would be rules, assumptions and experiences to get at the core beliefs.  People often manipulate the world to confirm their hard core beliefs.  When peoples view of themselves becomes rigid, then they fail to learn, or to adapt to an ever changing situation.

The client has to want to learn before therapy can develop. The therapist needs to watch out for where the client  is tuning out what the therapist is saying to justify their view of the world. With slow learners then again its learning to learn that is the prime objective before specific lessons can be learnt.

Principle 9: The theory and techniques of cognitive therapy rely on the inductive method

If you adopt the scientific approach then beliefs are hypothesis and should be modified according to all facts. Conceptualisation, and treatment are all treated as experiements that are judged on the outcome.

Principle 10: Homework is a central feature of cognitive therapy

Doing homework ensures that work is done outside of the room, which is the aim of therapy to make a difference in your life.

Summary

Ok so Cognitive therapy is based on a dysfunctional thought maintains disorders which affects behaviour and emotion. It is time limited and problem focussed. It is only on the basis of a good relationship that it is enabled. Throughout the work it is a collaborative empiricist method, where you work with your client and test conceptualisation, intervention  and assignments. Homework is critical as it extends the amount of time that you can get an impact from therapy. There probably is more but Im tired and it was something of a summarised chapter anyway.

Chapter 11 Strategies and Techniques for Cognitive Restructuring

Developing Self Awareness

On the assumption that thoughts and judgements are highly influential in the impact of distress, then the initial goal in therapy is to become aware of your thoughts.

An initial goal in therapy is to help a patient restructure his thinking to become aware of his thought process. To be aware of your thoughts and emotions is the first step in changing them. The depressive patient brings depression into the room where anxious people rarely do. Patients holding back thoughts when asked are dealing with cognitive avoidance. Writing on a board can help put distance with thoughts and make it easier to write clients thoughts up. 

Mirrors are also useful to elicit self-judgements and can be useful when dealing with evaluative anxieties.

When people can’t remember their thoughts then you can also look to get them to remember situations that that situation reminds them of, and then look for the commonality (this could be useful).

Most efficacious to get a thought whilst it’s hot, in the room.  This means if you can evoke the feeling in the room, because of something that has happened in the room, then you can investigate the thoughts around it, likewise if you can do an in vivo experiment, go down the gym and see what thoughts they have.

People can use distraction whilst anxious that puts the thoughts associated with it to one side. You can increase self-awareness through distancing yourself, describing yourself in the third person. This gives yourself some distance from your feeling.

Directing Patients

People aren’t aware of their thinking as either they don’t think it important, it goes too fast, it’s so habitual that you don’t even become aware of it, and you effectively embed your thought in action.  Thoughts can be presented then as subliminal advertisements and by learning to detect them you can be aware of their effects.  Often a client will not own their emotions but rather say someone else caused it. In this area of owning your own emotions you can start to not ask why you are anxious but how you are making yourself anxious.

You need to get a client to experience anxiety to know what their thoughts are, so if they can’t remember, then get them to design a small experiment to produce some anxiety to see what their thoughts are, so going to the gym.  This can also mean staying with the feeling without using avoidance or any coping responses. So best to design an experiment that only produces a small amount of anxiety. In this vain then you need to have an inclusion strategy, to go to things you wouldn’t normally go to with a view to finding out what it is about them makes you anxious, what thoughts are going through your mind.

You can also manage your anxiety by referring to it from the observing self, so give your anxiety some distance, name it, and see what is going on for you when you have it.

Clients can also do thought records to elicit automatic thoughts.

Ways to elicit thoughts

1.       Psychoeducate

a.       The client in terms of the importance of thoughts that direct emotions

                                                               i.      Thinking there’s a bear in the woods

                                                             ii.      Picking a poisonous plant

b.      The nature of thoughts as automatic, subliminal messages caused through repeated thinking

2.       Evoke the emotion deliberately to investigate the cognitions

a.       Stay with the emotion longer by not using avoidance or coping responses

b.      Refer to the emotion in the third person, look rob is anxious, or look there’s anxiety again

3.       For a retold situation that are without thoughts, then see what other situations this situation reminds the client of and what the commonality is

4.       Write the initial thoughts up on a board, this gives some objectivity and helps elicit more thoughts

5.       Mirrors can be useful for evaluative anxieties

Strategies and techniques

A patient needs to slow his thoughts down to correct them, if this isn’t possible then you can simply count them. Doing this gives you some distance from your thoughts, gives you a sense of mastery over them, sees their automatic quality.

So to get control over NATS:

1.       Count

a.       This gives distance from the thought and increases objectivity. Observing changes behaviour and gives more choices. It will therefore increase the sense of mastery over them. You can also see the relation between the number of thoughts and the feelings of anxiety. It also helps not building on the automatic thought, it accepts it, counts it and lets it go.

b.      You can count over a duration, or a specific episode, or for specific time segments at random times

2.       Describe

3.       Challenge

Faulty thinking challenges:

Avoid answering questions for clients

1. Base each question on a rationale that relates to a conceptualisation
2. Use in depth questioning...can you think of anything more..take a couple of minutes and see if we can think of anything else
Three basic approaches
1. Where's the evidence?

2.  What's another way of looking at it?

3.  So what if it happens?

3 column technique...situation,thoughts, errors in thinking
To challenge the thoughts ask yourself what a good friend would say

Good homework is hypothesis testing

Anxiety has a footprint of narrow disaster laden interpretation, generating other ways of looking at something is key.
Anxiety prone clients tend to overly personalise things and see them having an excessive amount of control for negative outcomes. Reattribution is the process of diminishing agency for negative outcomes. You can do this via a responsibility pie

Decatastrophising
How probable is the prediction?
What would you do, is coping plans?
Point and counterpoint, I say the fear you say what you can do to cope...then swop

Counting Automatic thoughts

So to get control over NATS:

1.       Count

a.       This gives distance from the thought and increases objectivity. Observing changes behaviour and gives more choices. It will therefore increase the sense of mastery over them. You can also see the relation between the number of thoughts and the feelings of anxiety. It also helps not building on the automatic thought, it accepts it, counts it and lets it go.

b.      You can count over a duration, or a specific episode, or for specific time segments at random times

Questions

Questions can be helpful to challenge automatic thoughts:

1.       Where’s the evidence?

2.       Where’s is the logic

3.       Are you oversimplifying a causal relationship

a.       Does one mistake lead to a disaster, have you seen other people making mistakes

4.       Are you confusing habit with fact

a.       Is this thought coming from reality or from my habitual thinking

5.       Are your interpretations of the situation too far removed from reality to be accurate?

a.       If you stick with your five senses, then you become more attached to the situation and will be more accurate              

6.       Are you thinking in black and white terms when almost nothing is either or

7.       Are you talking in extreme words, words like to be, always, never, forever rarely correspond with reality. Likewise the to be verb is rarely accurate, to say I am anxious is extreme, to say I have anxiety is more accurate

8.       Are you using cognitive defence mechanisms, i.e. making an excuse

9.       Are you thinking in terms of certainty or probability

10.   Are your judgements based on feelings rather than facts

a.       Some people use feelings to justify facts. Because I feel anxious therefore there must be something to fear

Guidelines in asking questions

1.       Avoid answering the question

2.       Be specific and concrete and avoid labels

a.       This keeps the client focussed and describes in better detail their problem

3.       Base each question on a rationale

a.       The conceptualisation

4.       Questions should be well timed and aim to foster  rapport and problem solving

5.       Avoid a series of rapid fire questions

6.       Use in depth questioning, don’t necessarily accept, after you have listened to the first answer

Three basic approaches

Anxious clients believe something bad is going to happen and they won’t be able to handle it. The therapist’s response is three fold

1.       Where’s the evidence

2.       What’s another way of looking at it

3.       So what if it does happen

Where’s the evidence

If there’s a specific fear then you can ask where’s the evidence that this is going to happen. If there is no specific fear then you need to find one.  With a specific fear you can use a three column approach. What the situation is, what the interpretation is, and what thinking errors are there. If you can’t use thinking errors then you can ask what would an objective observer say, or a trusted friend. You can also use hypothesis testing, so write down the feared consequence then see what happens.  So if someone thinks I’m too anxious to do x, then break x down into small pieces and see what they can do. When no evidence is found of the feared event then anxiety will be lowered.

What’s another way of looking at it

Generating alternative interpretations. If there is a dire prediction are there any alternative interpretations that can be created. This can be done in a two model form, one with the dire interpretation and the other column the alternative interpretations. By considering other interpretations the anxiety can be lowered. 

DTRs can also be used to generate alternative ways of looking at something. 

Decentring is the process of getting some perspective on yourself and also seeing that you are not the centre of attention. To do this you can establish some concrete criteria to establish if people are paying attention to you.  To do this you need to watch other people and see how they are responding, the effect of this is to take the focus of yourself and onto others. This works very well with social anxiety as the self has become the focus for attention and creates the anxiety and when you are looking at other people then you lost the impact of this self-focus.

Get better instead of feeling better is a useful mantra.

You can also look to enlarge perspective so if you feel anxious about x, find out all the good things about x.

Reattribution: in anxiety you can attribute a lot of negative outcomes to be your fault. To reattribute is to say are they really your fault are there other factors involved, do a responsibility pie.

So what if it happens

Decatastrophising

So if it does happen so what? Play the scenario through, I may go mad, what would happen, how would you cope

Coping Plans

Look to provide coping plans for if the worst does happen

Point\Counterpoint

Client gives fearful idea, you say why it’s not so fearful, using either coping plans or decatastrophising. Four ideas are covered in this:

1.       Probability of the feared event

2.       Its degree of awfulness

3.       Client ability to cope with it

4.       Clients ability to accept it and deal with the worst possible outcome

Summary

Thinking is the key in cognitive therapy so this really is the centre piece. I guess the stages to get to here are firstly the client needs to buy into the relation between thinking and anxiety. Anxiety is fear of something, then there is the anxiety response which can be fight, flight, freeze or faint.  The anxieties that we have around dark spaces, being away from a caregiver, being afraid of bears are all learnt behaviour and are the basis of judgement. So let’s find out what that judgement is. The other issue with anxiety disorders is where the warning systems within the fight, flight, freeze and faint responses and anxiety itself are seen to be something to be afraid of, this creates a vicious cycle.

So the first thing we need to do is to find out what you are afraid of, and what the judgement is about this.

So when a client feels anxious then we need to find the thought behind this. To find thoughts then what you need to do is:

1.       Ask client for thought

a.       Probe deeper to find out if this is the main concern

2.       If no thought comes then

a.       Ask the client to think of similar situations and see what is in common with this one

b.      Write base thought up on board to give client some distance from it

c.       Recreate the feeling of anxiety in the room, or in vivo and get the client to see what their thoughts are

d.      Get the client to stay with their emotion without using avoidance or coping responses

e.      Get the client to give some distance from their anxiety by referring to it in the third person

3.       Once you have elicited the fear then you need to get control over it

a.       Count the thoughts, this gives distance a sense of mastery and will change behaviour by observing it, so you will act out less on it

b.      Question the thought

                                                               i.      Where’s the evidence

1.       Do experiments, predict and see the results

2.       Get the client to write down the evidence

3.       Three column technique

a.       What happened

b.      Interpretation

c.       Where the thinking errors are

                                                             ii.      So what if it happens

1.       Could you cope, how would you do it? The aim here is to show that you would actually cope, so it produces coping plans

2.       Point\Counter point. This works between client giving fear and therapist giving counterpoint to it

a.       Counter points are probability of it happening, coping response, how bad it really is, ability to accept it

                                                            iii.      What’s another way of looking at it

1.       Thought records

2.       Two column technique, what’s the feared outcome and what are the alternatives

For people with social anxiety, then a decentring technique can be useful, so focus on other people to observe and look for concrete criteria of disapproval.

Reattribution:  here if there is personalisation at stake then do a responsibility pie.

Chapter 12 Modifying Imagery

Most anxious clients have an image before and during their anxiety. Images can produce the same reactions as if something is actually happening. If you hold the truth of an image despite contradictory information then its an hallucination but if when you find contradictory evidence you don’t, then it’s imagination.

Induced Images

It has been shown that using relaxation then imagery can help prepare sports men for sport and can reduce anxiety, and help with childbirth

Delineating maladaptive patterns

For clients who are having difficulty remembring then get then to imagine and make an image. Likewise if you have an emotion about a situation but you don't know why then use an image.

Pinpointing cognitive distortions

If thought work doesn’t get anywhere look to use images. Get the client to imagine a picture of their feared situation.  Once the image has been brought out then it can be reality tested. Likewise brining up an image of a feared situation can put reality into a situation that pure thought lacks.

Modification of induced images

If you repeat the feared image, then a modification should happen. What can happen is the first image relates to primal fears, the second image to more current concerns. So a childhood fear to a an adult competence.

Techniques for modifying images

Turn off technique

You can turn off an unpleasant image by using sensory input, e.g. clap, blow a whistle... Or concentrate on immediate environment  then replace with positive fantasy.

Repetition

When clients repeat their images then they change just slightly in content, this will be followed by a persistent change in attitude. With deliberate repetitions then you tend to get closer to reality at each pass. Anxiety generally drops with each deliberate repetition. If repetition happens naturally then you get no reduction in affect, but if you consciously, deliberately repeat then you do.

Time projection

If you are upset about a particular situation project yourself in to the future to gain perspective on your current trouble. I think the situation needs to be distinct, e.g. worry about x, rather than I am depressed at the moment as otherwise the future will be grim as well. Good example worried about husband being unfaithful, what would it be like after a week, 6 weeks, 6 months,.

Symbolic images

Use a symbolic image to address the problem and the solution, so if a person has writers block imagine an old rusty pump that takes a bit of time to get going then flows water.

Decatastrophising the image

So what would happen if your worst fears came true, you actually probably could cope. If you focus on the feared outcome, prepare for that, anything else will be a bonus, you are in the shit, things can only get better. Sometimes clients prematurely close down images, and shut it down with childish words like this is silly, stupid etc. Then the image comes back stronger, you can then use the so what if technique, which says so what if your worst fears came true, and the underlying thought is that you could cope, so you need to make sure that there is enough time in session to enable this. People discount the amount of rescue factor, for every danger there is some rescue around for it.

What happens is that the image stops at the feared event, then there is a dreadful feeling of not being able to cope with it. If you roll the image forward to what happens next you would find out that you can cope. It’s almost like a downward arrow technique with coping attached to it.

You can only use the what if technique after you have a good relationship, as it needs trust to be effective, as you need to take a person through their worst fears. The so what if technique is a cognitive flooding technique. So again you need time in the session to let the anxiety reduce. Anxiety can reduce by realising it’s a low probability, realising for every danger, there is a rescue factor

Images and thoughts

Undesirable images often have accompanying thoughts alongside the image, what if that happened to me. These thoughts then can increase the extent of the anxiety, so you get image one, then cognition 1 which can lead to image two and cognition two, and you get an anxiety spiral.

Facilitating change in induced images

What you can do is from a negative image, then little bit by little bit, change the image to become a positive one. Imagine the image is like a movie and you are the director and you change one bit at a time.

Substituting positive imagery

Develop an independent positive image that can be used as a diversionary tactic after a stop; can also be used to get to sleep.

Substituting contrasting imagery

If the fear is of disaster then create an alternative image of success and substitute the former with the latter.

Exaggeration

Here you can exaggerate your worst fears to hyperbole, which then puts your current fears in perspective. You need to emphasise that thoughts don’t lead to action.  This seems like a scary technique if violence is used.

Coping models

Imagine someone you know coping with the feared situation or imagine yourself to be a certain person, George Clooney if you have social anxiety.

Imagery to reduce Threat

Intimidated by someone, imagine them in shorts  or on the throne, interviewed by a panel, imagine them as lambs and  yourself as a lion. You can also do imagined walk throughs of feared situations.

Escaping a worse alternative

Imagine something really terrible, chased by a gang and you manage to duck into a room and perform your feared action, e.g. a recital.

Mixed Strategy

Literally mix and match the above techniques

Future therapy

Patients often have a grim imagined future. So create a better imagined future. Wait until anxiety is at a low point, get patient to imagine a date in a few months then ask what they would have liked to have happened by then. The therapist then interviews the person as if they are at that date, asking about his new attitudes and behaviours. He notes what areas give him trouble and what don’t. To get the movement between now and then, rate yourself on a scale now and then, then imagine the movement between the two. The patient needs to choose goals that are under his control otherwise he is setting himself up to fail. After you have developed your three month goal, imagine what it’s like on that day being successful, feel the feelings, see what you see etc., then imagine what it’s like on the day being successful, then work out what you are going to do to get there. One of the key ingredients in creating the future is repetition. You can see how repetition works by the use of advertising. So imagine the future goal as often as possible. Feel the feelings associated with the goal

Goal rehearsal

Imagine your goal and how you will get there. This will mean that you practice the various steps in imagination and then be prepared for their eventuality. This increases coping strategies.

You can use future autobiography, so interview you in the future after you’ve overcome your goals to know how you overcome your obstacles to your goals.

Also look at the common strategies you use to stop you getting goals.

Summary

Images and imagination is an important area. If cognitive approaches don’t work directly then imagery work can pay dividends as a client may hold more of their cognitions visually.  It is seen that most anxious clients have an image before they feel anxious.  If this image can be brought out then the cognitions that are attached to it can be brought out. When they have been brought out then they can be challenged, via where’s the evidence, so what if (decatastrophising), what’s another way of looking at it.

If cognitively getting involved with the image doesn’t work then you can try manipulating the image directly of which the following techniques are available

1.       Repetition

a.       Repeating the image will make it become more realistic

2.       Time projection

a.       Imagine a time 3 weeks hence, 6 weeks hence which can show you how you cope with it

3.       Exaggeration

a.       Exaggerate the image to put your current fears into perspective

4.       Modifying

a.       Modify the image, sharpen, blot out, until you change it to a more acceptable image

5.       Replace

a.       Get a more pleasant image to replace it with, use the stop technique to move between one and the other

6.       Comedy

a.       If threatened then imagine your persecutors as cartoon characters

7.       Symbolism

a.       Imagine a symbolic representation of you overcoming the feared image

8.       Escape a worse alternative

a.       Imagine a terrible alternative and you

9.       Turn off technique

a.       Here you can either use a noise or concentrating on the current situation to stop the image

10.   Decatastrophising

a.       Here imagine yourself coping, list all the coping response that you could do and imagine yourself doing them

11.   Role model

a.       Imagine a role model in that situation, then imagine yourself as that role model

Chapter 13 Modifying the Affective Component

Modifying the affective component means (AWARE). Accept the anxiety, watch the anxiety, act with the anxiety, repeat, emotional review and owning one’s own emotions. The below are strategies to achieve this

1.       Accepting the feeling

a.       Once anxiety is at a certain level then you can’t control it, but paradoxically through accepting it, you will control and reduce it. When you are afraid of anxiety, you are afraid of your feelings of anxiety not anything else and by accepting these feelings you can lessen them.  Acceptance is acknowledging the existence of an event without placing a judgement on it. Value judgements on the anxiety only deepen the anxiety and should be avoided.

b.      Patient may fear bad things will happen because of his anxiety, i.e. social disapproval, going mad, loss of control. Anxiety about anxiety is about these secondary problems. Anxiety comes in waves has a beginning , a peak and an end, even though it might reoccur there is a still period between instances.

Accepting the feelings

Clients want to fight the anxiety, but once it reaches a certain level then you can’t control it and you must accept it. What you fear is fear and anxiety and the feelings associated with it. This may not entirely be the case with social anxiety where you fear not being invited to the party, but let’s face it there are many parties. People fear going mad, but this is cognition about what anxiety means.

Reducing anxiety about anxiety

Anxiety can be seen as that which makes you go mad or suffer permanent psychological damage. How bad does your anxiety  feel, if you had to rate it against the worst possible pain and the mildest pain, where would it be? Anxiety doesn’t go on for ever it starts, reaches a peak then subsides. It comes in waves and can return but it doesn’t deviate from this pattern.

Anxiety myths

1.       I can’t function, many people can even when they have anxiety, its only when you don’t believe you can that  you stop trying

2.       I will lose control, this isn’t the case a  person may become rigid trying to hold themselves, but not lose control

3.       I may go crazy: there has been no incidents of anxiety causing madness

4.       Anxiety means feeling shameful: it’s a childhood notion to think that you will be judged as weak, foolish or inferior for exhibiting anxiety

5.       I will go mad, you may feel you have lost control, but its only because you stop trying, even if you have stopped trying anxiety will go away and control will return.

Reducing shame about showing anxiety

If a patient adopts an anti-shame philosophy towards his anxiety then he can avoid much pain and discomfort. If he adopts an open door policy and tells other people that he felt anxious then he can reduce his feelings of suffering

Common beliefs about anxiety

1.       Feelings of shame having anxiety as others think I’m a fool

a.       What do you think of other people having anxiety? If it is low, it may explain your feeling of what others think, but usually they don’t have a negative opinion

b.      Ask others what they actually think

2.       It shows I’m weak

a.       But what would a person with no anxiety be like, the macho happy warrior stereotype from society

b.      From a physical point of view it is irrelevant

3.       I’m neurotic

a.       This is a label with no specific validity. Anxiety is merely a specific symptom that arises in a specific situation

4.       Others can tell I’m anxious and are put off by me

a.       Probably an exaggerated view that others can see this. There’s no necessity people are put off by it, if people do have a negative reaction then they are not necessarily correct. He can check if people can see he is anxious by asking them

5.       No-one else gets as anxious as I do

a.       As much as peoples empathy might get discounted so can other peoples experience of anxiety, most people get anxious at one time or another

6.       They will reject me

a.       Rarely is a person rejected just because they are anxious rather people see it as a transitory situation like having a cold. People can reject people for a myriad of minor reasons

7.       I look ridiculous

a.       Other people may label you as that, but to label yourself is unhelpful and unproductive

8.       Since I have appeared anxious nobody will want to be my fired

a.       Where’s the evidence. Have you appeared anxious to friend before and lost them

You are not your anxiety, it is a feeling that you have. If people downgrade you because of this, there is no point in buying into their adolescent attitudes. Albert Ellis has done a tape how to stubbornly refuse to be ashamed of anything.

Normalising anxiety

One way to reduce anxiety is to help the patient become less self-absorbed and to act in spite of what’s going on.

There are the symptoms of anxiety, then a thought that these are dangerous somehow, or say something bad about you. This creates more anxiety. The more anxious you become the worse it becomes and you have a vicious cycle. When you become hyper vigilant on your symptoms then they become stronger.

Strong emotions are signals that you need to correct the way you are engaging with the world.  Anxiety is a call to you that you need to act or think differently.  Anxiety says either you are in danger or you think you are and need to think more realistically. By acknowledging painful emotions then you send the signal to the brain that you are responding to this and the feelings subside.

Anxiety can give you an edge in performance.

Active Acceptance

Choosing to accept, welcome say hello to anxiety takes some control over it. Sometimes telling people you are anxious can help, e.g. in a presentation.  Acceptance is an active not a passive thing.

Identifying Emotions

Mad, sad, glad and scared are the four basic emotions and all other emotions are a mix of this, for instance hurt is sad and mad. Most anxious patients have had the glad\scared mix, e.g. on a roller coaster and one of the most common mixes for anxiety is scared\mad.  There are many secondary feelings about anxiety, sad, shame etc. that can get in the way of dealing with the feeling.

Action strategies

Getting a client to act as normal as possible lessens symptoms, if you run from a situation your anxiety will decrease but your fear will increase, but if you stay both will reduce.

Activity schedules

Planning a schedule provides the patient with a sense of direction and control and is an antidote to feeling overwhelmed, it can also provide a distraction from anxiety. Finish one task and do something pleasurable as a reward. The goal is to engage in activities not do them perfectly. Activities that absorb concentration are best.

Increasing tolerance for anxiety

Increased tolerance decrease the amount of anxiety about anxiety. With practice people can learn to increase their tolerance for all sorts of discomfort.

To increase tolerance, then you need to decrease escape behaviour and diversions or increase the level of time before reaching for these. Doing this tests the thought I can’t cope with anxiety. If there’s the thought of I can’t cope with this pain, then construct a pain hierarchy. You can break anxiety by having a cold shower or going for a run

Alcohol, stimulants, diet, stress

Patients with anxiety are urged to avoid high levels of stimulants, or indeed sometimes any as the effect may be misconstrued to be anxiety. Also avoiding being too low on blood sugar, so eat regularly is recommended.  If low blood sugar is suspected then eating protein is recommended. Stress, fatigue or lack of sleep can increase predisposition to anxiety.   Likewise avoid anything that can subdue the effects of anxiety but that don’t help to manage it.

Maladaptive coping behaviour

Secondary behaviours that originated as a coping behaviour for anxiety, e.g. alcohol or eating become embedded and autonomous. Interventions included graded task assignment, pleasure and mastery schedules. With these behaviours that become automatic coping response, then breaking the chain can be useful, this prevents the behaviour from being automatic and running away. Again to increase the amount of time before the coping behaviour is adopted will always be an improvement!!

Self-Observation

The observing self is non-judgemental and won’t get caught up in the subjective drama of anxiety. The observing self just describes the situation.

To observe yourself without judgement gains perspective and embeds the person in a wider context. The awareness brings the person back to the present and out of the anxiety whole. Anxiety is the outcome of projecting oneself into a dangerous situation in the future, by remaining in the present then this can reduce this happening. Rather than thinking I am anxious, think I have anxiety.

Why questions in self-observations can promote more anxiety, however how and what questions provide a greater description and more.

Homework that is more in the line of putting the person as investigator\explorer in more likely to have a better outcome than just giving someone an activity to do. The reason for this is that they become more of an observer if they investigate and explore.

To get good observation then you need to detach yourself from core schema or these cloud your observations. You can get more observation when you watch yourself watching, depersonalise, you do this automatically in anxiety but doing this deliberately can reduce anxiety.

Positive Self instruction

Instead of telling yourself not to be anxious, tell yourself things that you can do, such as observe yourself, it will go, be alert, this will decrease the feeling of helplessness. If you tell yourself something you can’t do you are setting yourself up to fail, if you tell yourself things you can do this increases your sense of mastery. So instead of saying don’t spill the coffee, which will increase the chances of spilling it, say be careful carrying the coffee. Also there’s the sense of detaching feelings and thoughts from self. I am not my body, I have a body. I am not my thoughts, I have thoughts. I am not my emotions I have emotions. All this does is increase the awareness you have of your situation and decrease your identity with the problem, it gives you a sense of control and mastery

Graphs and diaries

Recording the situation and intensity of anxiety, via Suds show the client that anxiety is time limited and generally related to external situations. This counters the client feelings that their anxiety will never end

Concentration (or distraction) exercises

Get the client in the room to get anxious, then focus on an item in the room and describe it in detail and watch how the anxiety goes down. If the client isn’t anxious then get them to imagine an anxiety making situation, then if that doesn’t work, use hyperventilation. The technique here is that by focussing on an external event then you don’t focus on an internal event, and focussing on anxiety holds it up.

Relaxation methods

Relaxation methods reduce symptoms and are a means to an end.

Letting go, means that you are more in control!!

1.       Tense muscles, hold breathe, release, purse lips and slowly release and notice the difference and the sense of relaxation.

2.       Take long breaths and let them about slowly

3.       Stretching time, count every second, then every 30 seconds, imagine the past is way in the past, and the future is way in the future

Emotional Review

Go over a feared situation in the office, and tell the client that the pain is like a lump of pain that can be smoothed out. So repeat the description of the feared event several times and you start taking a different perspective on it. This also decreases the sense of avoidance tendencies. This increases observation, by more identifying with the observing self rather than the anxious self then anxiety decreases.

Over time worries are replaced by other worries, repeated review merely speeds this process. This is very similar to a flooding process, and enables a client to work through the feared event, to prepare an emotional response. One of the main gains from this is also to counteract the avoidance tendency. It also provides some distance from the situation. Repeated reviews also enable underlying fears to be made apparent. Through the repetitions through the cycle a client can often access more of their coping responses, more reality and allay their fears.

Imagery methods

Imagine in detail the feared situation in detail pre talking about it. This can help for people who can’t talk about it, so you can do an emotional review using images, then get the client to describe it.

Metaphors

When talking about it, or imagery hasn’t been successful, then metaphors can be used. So look for the clients’ interests, or assets, and use a metaphor in that vain to explain the situation. This can increase a feeling of strength in the situation as you are appealing to a person’s stronger side.

Repeated review outside the office

If a client has trouble reviewing outside of the office then here are some guidelines

1.       Give yourself plenty of time

2.       Repeat until the anxiety diminishes

3.       If there are a stack of problems do one at a time

4.       Review the problem in slow motion

5.       Describe the problem rather than judge

Owning ones emotions

Most anxious people believe that the thing they are anxious about is causing their anxiety not themselves. So if an event precedes the anxiety then the event causes the anxiety. Anxiety is in some ways a primitive response and can cause other aspects of primitive thinking

Sequential reasoning

When you ask a girl out or go for a test you get anxious then this is about your opinion and belief nothing intrinsic about asking the girl out.  For instance if you ask a girl out you like and a girl you don’t like then you have different emotional responses, so there is a belief in there that explains your emotion. Therefore you create your emotions.

Correlational reasoning

Something may appear with something else but not cause it.

Analogical reasoning

You may feel like you are going crazy when you have anxiety but this is a feeling not a fact. Physical pain can be caused by others, but emotional pain is caused by yourself.

Emotional reasoning

Because someone feels that others cause you anxiety doesn’t mean that is the case

The Payoff

There is sometimes a secondary gain from anxiety, so ask what would you have to give up if you let go of your anxiety. Emotions may draw attention to you.  The payoff may not be the motivation for anxiety but can make it harder to shift.  Emotions can act like adverts they grab our attention, they hold our interest and then motivate us to take action. The secondary gain then can be the emotional equivalent of the payoff in adverts.

Special treatment

Anxious people have fewer demands put on them

Help

People help, pay attention to, stroke an anxious person. This can be an obstacle to getting better as it asks the other to take charge of you, where you could do that for yourself.

Lack of risk

With anxiety you don’t have to take risks and you avoid the chance of failure

If only

Can maintain the idea that the person is superior if only they didn’t have anxiety

Justification

Can justify secondary activities, e.g. smoking drinking etc.

Special privileges

If having an anxiety attack so I must be by myself

Role of victim

The only way to get love is to see myself as not ok

You can deal with secondary gains by looking at other more direct ways of getting them, stressing that indirect is less effective as you have to get more dramatic and effective to get the pay off.

Summary

Ok to modify the feelings of anxiety the following is an approach

1.       Accept the feelings

a.       Dispel the  myths: ask the client what they believe about anxiety and challenge the dysfunctional attitudes which may include

                                                               i.      I’m weak

                                                             ii.      I’m going mad

                                                            iii.      Others will reject me

                                                           iv.      I’ve got something wrong with me

                                                             v.      I can’t do anything when I have anxiety

                                                           vi.      I will lose control

b.      Normalise

                                                               i.      Everyone gets anxiety

c.       Active acceptance

                                                               i.      Name the anxiety as part of you, refer to it in the 3^rd person

d.      Rate the feeling

                                                               i.      Compare how bad it feels in comparison to other imagined pain

e.      Reduce the shame  of anxiety

                                                               i.      Operate an open door policy and tell other people about your anxiety

2.       Take action

a.       Activity schedules

                                                               i.      If you plan your day then it can give structure where when you anxiety you can lack it

b.      Increase tolerance for anxiety

                                                               i.      Reduce time to go to escape behaviours, show that you can tolerate the levels of discomfort

                                                             ii.      Use the distraction technique, focus on some external object to reduce internal focus

c.       Substances

                                                               i.      Avoid substances and behaviours that make you more vulnerable to anxiety, and cut out those that avoid it

d.      Maladaptive coping behaviours

                                                               i.      Avoid alcohol and escape behaviours as whilst it makes you feel better it doesn’t make you get better

3.       Self-observation

a.       When you observe you take a distance from yourself and give yourself more options. When you observe ask  yourself how and what questions be an investigator and explorer, describe your circumstances, your thoughts and your feelings

b.      Give yourself positive self-instructions, say carry the coffee carefully, don’t say don’t drop the coffee

c.       Graphs and diaries can help to show that anxiety comes and goes

d.      Use concentration on external objects to stop the internal focus which maintains the anxiety

e.      Use relaxation to reduce anxiety

                                                               i.      Slow breaths

                                                             ii.      Progressive muscle relaxation

4.       Emotional Review

a.       Doing an emotional review is a flooding technique. You repeat the story over and over, during each iteration then you will find it changes, you will find your anxiety reduces. If you find it hard to talk about it then you can use images. Again look to describe rather than label. You will get closer and closer to reality through each iteration.

5.       Own ones emotions

a.       First of all use logic to show how emotions are created

                                                               i.      Asking two different types of girls out and how your emotions differ, so it’s your beliefs about these two girls that create your emotions

                                                             ii.      Show how emotions and physical sensations differ and that we use the physical explanation to

b.      Show how secondary pay offs can maintain the emotions

                                                               i.      Special privileges

                                                             ii.      Getting help

                                                            iii.      Getting attention

                                                           iv.      If only, justifying high status

                                                             v.      Justifying secondary acts like drinking

Chapter 14 Modifying the behavioural component

To deal with anxiety you need to get the patient to face anxiety provoking situations and to practice specific coping techniques. This can be done in the room by imagination or in vivo. Here they can look at their thoughts and beliefs with a view to modifying them.

Identifying Protective mechanisms

You need to find out what techniques the client uses to decrease their feelings of anxiety. There are two main mechanisms, flight/avoidance and reassurance.

 Often flight, or avoidance is used to diminish anxiety.  You will also see attempts by the client to reassure themselves, either through checking with the other or by continually appraising the feared situation. The client may also respond to the situation by freezing, tightening muscles, in which case the therapist needs to get the client to let go, relax.

In summary then a client will avoid, seek reassurance and freeze. So the work is to stand in the face of the feared situation, relax and not seek reassurance.

Motivation

Explaining the therapeutic approach to the patient

The context when you learn is the context when you can recall. So learning something whilst drunk will mean you can only recall when drunk. Likewise learning how to manage anxiety must be done when anxious.  There is a gradient here, learn in a safe environment, then learn in a more challenging one.

Blocks to learning

When difficult material is brought up the client may yawn, say he’s tired, become irritable, angry or bored. It can be useful to look at the beliefs that prevent a client from learning, i.e. I’d be inferior to the person who teaches me, I’d be a phoney, I can’t trust myself etc.

Likewise a client might verbally agree, but then do nothing about it.  To get a change you need to have a connection between thoughts, actions and feelings. Actions speak louder than words. Learning is a combination of intellectual learning and experiential learning.

You need to address and deal with these blocks to learning before learning takes place, however you would only address them if they came up in the room and not force the issue.

Learning can be agreeing with a proposition but not incorporating it into beliefs. Incorporating it into beliefs but not acting on it. To get full learning then proposition, belief, emotions and actions all need to be related.

Educational devices

The following educational devices can prove handy

1.       White board

a.       This can provide objectification of ideas, gives clients some distance from them and allow them to observe them and therefore think about them.

2.       Audio tapes

a.       Clients may dislike listening to themselves but repeating this leads to greater self-acceptance

b.      Often anxious patients have difficulty remembering the session and this can help

3.       Video tapes

a.       This can show that anxiety isn’t as publicly obvious as is thought

4.       Hand-outs

a.       This enables repeated review, to establish learning and recollection

Futility of self-protection

Need to psychoeducate to see how avoidance and protective measure strengthen the unrealistic, unhelpful thoughts. The more you protect yourself from bad feelings, the more ominous they become. You need to face your fears to overcome them. Each action strengthens the ideas underpinning that action, so if you avoid something because it is fearful, then it strengthens the idea of it being fearful.

Experiments

Approach any homework, or activity as an experiment to see what can be learnt.  So it’s all very well logically disputing an idea in a session but to do an experiment and put it into action will reinforce the position.

Graded steps or a gradual approximation

Clients have often faced the feared situation but done so in an all or nothing approach, taking smaller steps can make this easier, as it builds up learning, strengthening of will and self esteem

Hierarchy

Create feared hierarchy, stay in each step until the anxiety develops and you can move onto the next step. If the step is too great, go to the previous one.  This also helps as a global problem can be broken down into a series of steps.

Aids to exposure

Initiation technique

1.       Tell a friend, make a public commitment

a.       However just state this as a serious intention as if it does go wrong you don’t want the client to be depressed

2.       Homework (a private commitment)

a.       Doing any sort of homework, gets a foot in the door to getting homework done, but you need to get some sort of result out of doing it, so you need to review in the office.

b.      Use reinforcement strategies, what are the rewards that you can give yourself for doing homework?

c.       Stress the value of homework, that it increases the amount of therapy that you are getting

d.      Practice homework in the office

e.      Develop collaboratively

f.        Explain the rationale

g.       Treat each piece of homework as an experiment

h.      Ask about any obstacles that there could be to completing homework

                                                               i.      You could also do a future biography

Self-instruction

You can use self-instruction to help you enter the anxiety making situation, so there can be some motivational phrases that you use.

Use coping statements, e.g. anxiety isn’t dangerous, it will subside. These are the self-same techniques that advertisers use. Repeat these phrases in a self-confident and self-assured manner.

You can also use a role model, how would they act, or maybe a symbolic object, a stone to represent being strong.

You can also invert statements, so when you say I hate filing, say I love filing and shout it from the roof tops.

Behavioural rehearsal

In this role play then the therapist can model the worst possible fears the client has. Of course you need to build up quite a level of trust to do this.

The use of significant others

Significant others can help the client stay in the anxiety longer, they can

1.       Reinforce small steps

2.       Encourage don’t pressure

3.       Make the process a collaborative effort

4.       Let the client take the lead

Notice the difference between feeling better and getting better, one strategy changes the feelings temporarily the other takes them away.

Technical aids

Cognitive avoidance

A client may enter a feared situation but avoid thinking about it, then they must be reminded to keep their thoughts, emotions and behaviours all pointing the same way to get the most benefit out of facing their fears.

The critical-decision technique

In an anxiety making situation there are a chain of behaviour up until the critical decision to avoid.  This chain of decisions will somewhere include within it a decision and a self-instruction. When this position comes then you need to take the opposite form of action, instead of avoiding then being with, engaging with or acknowledging your fears, so if you are social anxious instead of leaving go and talk to someone.

There’s a paradox with anxiety that when it’s applied to psychological aspects it’s better to face your fears than run away, to protect yourself makes you more vulnerable. Anxiety is a very primal system that helped us with physical threats many years ago, and now it’s better to face our fears. What then, if your fears are realised, you have anxiety about dark alleys, walking down dark alleys would not be sensible, so how do you tell if your anxiety is sensible or not. Does the anxiety stop you doing something you want to do? Is the anxiety a psychological issue? Is it a reasonable level of anxiety for the situation?

So when the anxiety isn’t justified, then do the opposite of your instinct. So if you want to leave a party as you are feeling anxious then stay. People say this feels phony when you do, but any new behaviour feels uncomfortable when you try it.

Surprise

Why don’t you surprise yourself and see what happens

Choice

People who have lost trust over themselves and their situations seek to get unreasonable levels of control, they mentally rehearse to ensure control over a situation. However the concept of control is an illusion as you really don’t have control over what you’re going to think or feel and none over the environment.  So instead of thinking in terms of control think in terms of increasing or decreasing levels of choice.

Task orientation Tic\toc technique. Task interfering cognitions, task orientated cognitions.  Tic=I’ve got to get out of here, Toc=what can I do to get what I want out of this situation. Toc think of your purposes(s) and the means to achieve this, recognise thoughts that get in the way and replace them with more helpful thoughts.

Behavioural thought

Given an anxiety what can you do to alleviate. Afraid of breaking down in the car, join the AA

The As if technique

If you are anxious about not having confidence, try acting as if you had confidence and shortly you will find that acting in the way that you want to will eventually bed in. You can do this via imagery and imagination and also role play.

Shame and other feared experiences

Most anxious patients are afraid of feeling shame, therapy provides the opportunity where you can deliberately experience shame. To desensitize yourself to shame you have to give yourself shame.  So that what you can do is find out what is most feared, being not nice, taking criticism, being rejected. Then you can rate behaviour that would encounter that and give yourself points for each time you experience it.

Developing self confidence

Increasing self-confidence can decrease anxiety. So afraid of being by yourself, do more activities by yourself. Anything that enables you to manage your fears increases confidence. In a social encounter there are generally four options say nothing, agree, disagree, change the topic. People are fascinated by silence and what lies beneath the mystery. Self-confidence increases with knowing you can handle risky situations, so take a risk just for the sake of it.

Agreeing

Sometimes anxious people can fend off both criticism and compliment, which provokes more attention that they don’t want. So to reduce this then with criticism you can say thank you for bringing this to my attention, and with compliments you can say thank you I like it myself.

Disagreeing

Try disagreeing twice and that’s it, its ok to disagree and still remain friends.

Doing the unexpected

In sales whoever answers the question first loses..If you don’t want to answer a questions answer with a question.

Making a mistake part of the show

Make any mistakes you make part of the show. Like they say in jazz, if you make a mistake, play it again.

Summary

Ok, so behavioural work to deal with anxiety.  There are 4 aspects of dealing with anxiety, you first of all need to know what the usual responses to anxiety are, flight, avoidance, coping responses and are they functional. Once these have been highlighted then you know what exposure means, i.e. doing something without resorting to these dysfunctional coping mechanisms.  To motivate a client to expose themselves to anxiety, then find out:

1.       What are the blocks to learning

2.       Self-protection with anxiety is futile as it doesn’t go away, the only way to get it to go away is to face your fears

3.       Create a graded task hierarchy

The four aspects of dealing with anxiety

1.       Exposure

a.       To aid exposure then

                                                               i.      Tell a friend

                                                             ii.      Rehearse

                                                            iii.      Use Self-coping statements

2.       Acting as if

a.       Establish your fears and invert them and act as if they are true, use a role model from TV to help

3.       Shame

a.       Fearing shame can make you anxious so treat experience as an anti-shame technique and see how much you can cope with, the more you cope with the less anxiety you will feel

4.       Developing self-confidence

a.       Establish your fears and create an anti-shame policy and put yourself in a situation to get this feeling

b.      Do the unexpected

c.       Expose yourself to risks

d.      Practice being silent, or disagreeing only twice then leaving it

e.      If you don’t accept compliments or criticism then you draw more attention to yourself so learn how to accept both

5.       Critical decisions

a.       There is always a self-statement and a decision before flight or avoidance, do the opposite of your instinct

b.      Surprise yourself

c.       Look for anything pragmatic you can do to make things easier

d.      Look instead of using control to giving yourself choices in a situation as you can’t really get control anyway it’s a myth

Chapter 15 Restructuring a patients assumptions and major issues

Anxious maladaptation’s are centred around acceptance, competence and control and are associated with particular domains, autonomous, sociotrpic, public or private

Identifying Assumptions

To establish what the root issues with anxiety are then you need to start with feelings and behaviours and then move to NATs and beliefs. To get underlying beliefs, get the patient who has a troubling situation, to think of the earliest time he has had a similar situation, get the image in his head, and say what belief he was operating from at the time. Anxiety will be created when a situation provokes one of their major concerns, vulnerability, acceptance or control, so whilst you can remove symptoms with graded task assignments, you need to work on the core schema to fully address this.

With any of the assumptions around

1.       Acceptance

2.       Control

3.       Competence

Then there is a feeling that there is a need around these assumptions and something bad will happen if they aren’t fulfilled, I must be successful, I must be loved etc.

Major issues

Identifying Major Issues

The major issues around anxiety are acceptance (other), competence (self), control (vulnerability). The major issues have been thought, felt and acted on thousands of time, are therefore fixed and habitualised. This means that the behaviour gains a life of its own, an alcoholic drinks because their team wins, draws, loses or doesn’t play. When they started it was probably only because they won. They then develop a lifestyle around this habit, his major concern.

Positive and negative reinforcers

If you fear incompetence then a positive reinforcer would be your career success that you use to prove you are not incompetent. There are negative reinforcers that you get when your fear isn’t realised then you are relieved. There can also be some social reinforcement where you join a group on the basis of your major concern, e.g. Mensa, the gym. 

A persons responses to their major concern also feeds it. So a person with control issues, tenses up when meeting a person in authority which provides them evidence that they can’t control situations with authority

Psychological double

Likewise people will seek partners on the basis of their major concern, so issue with control, then you find someone who is dominant.  The patients major concerns quite often generates two images, one is the one lacking the major concern the other is the overcompensation one. Thus there is fear that the feared image may come true, and the loved image may not be met

Development of major concerns

Feelings of lack of control often generates through a dominant parent. Major concerns develop in a spiral there is the initial concern that via a group of rules and assumptions generates its anti-thesis as a way of coping, but what happens is the original position isn’t challenged. You often create self-fulfilling prophecies \situations to justify your major concerns.  Selective abstraction also seeks to justify and embed major concerns.

Magical thinking, I had an image of the plane crashing so I cancelled my trip. Holding onto rigid beliefs, stops learning and excludes a whole bunch of reality that doesn’t fit with the rigid belief. Sometimes virtues stop you learning, so rename the virtue to a vice.

Shame is the biggest block to learning, pride is the next. You can be proud in your success area, and have no capacity in your problem area because your pride says I must be good, I’m not good in this area so don’t engage with it.  The person who does not learn from his mistakes will repeat them.

So the model is there is an ultimate concern then an opposite behaviour that compensates for it, both are held simultaneously. The opposite behaviour reduces anxiety about the ultimate concern but never addresses it. The client can shape their world to ensure that their ultimate concern remains true, so one therapeutic approach is to show a client how they shape their world to reinforce the belief they have, how they make the world fit their beliefs, how they narrow the world to achieve this.

Major concerns get fixed by developing your lifestyle around them, choosing partners, careers to support, using modes of thinking that keep them in place.

Acceptance

A core belief is that the client is flawed and will not be accepted by others. The development of this may have come from a lack of acceptance by a parent.   Clients overgeneralise and homogenise seeking everyone’s acceptance equally. Clients also see  acceptance or rejection is absolute. Other peoples acceptance affects his self-esteem, if he gets it he becomes more self-confident and contrariwise, thus his self-esteem is built on sand.  He believes mass acceptance is critical for his self-esteem. It is a difficult lesson in growing up to see that there is a world outside that has nothing to do with you. It is like wanting to be treated as the favourite child. If he hasn’t been given special treatment then he feels rejected. If I am to get anywhere I must be accepted by others, maybe even all others. He believes others are better judges of what is good for himself than he is. Therefore he must always be kind, generous and show empathy, this excessive concern shows that others know best, that others are critical to his self-esteem.

Within issues of acceptance there are issues of personalisation and narcissism. At one extreme I must be accepted by everyone to get self-esteem, as my fear is I won’t be accepted, things that happen outside of my  influence can be seen as related to me and signs of non-acceptance. I am the centre of the world and everything must connect and agree with me.

Competence

The core belief here is that he is inferior. He may well have been raised in an environment that supported this view, either family or society. He may be fearful of finishing projects, enlist other people to help and procrastinate. Sometimes are drawn to strong people who they see as superior to both draw from their strength but also to confirm them in their inferiority, The feedback as to whether one is competent is usually derived from the other.  

People with issues of competence are especially sensitive to people in authority, who can judge their inferiority. Competence is about evaluation and comparison.

Control

The fears of the person concerned with control centre on being dominated by the other or by events. Another pattern is where a child has had to live with ambivalent parents, not being able to get a consistent answer then they seek to overcompensate by seeking control over their lives.  The loss of control may be about a fear of going crazy and a panic attack. There is a belief in a dominance hierarchy where one is either a master or a slave. In some ways it’s not what control gives you the outcome, but it is rather the sense of being in control, thus the other has to give into my requests to ensure that I feel in control

Motivation and Major Concerns

Often a client wants to get rid of their anxiety but not their major concerns. You can loosen major concerns so move from I must be accepted to I’d like to be accepted, it would be nice to be accepted but it’s not disaster if I’m not.

Each major concern leads to a behaviour that reaffirms it

Summary

Underlying anxiety and other forms of symptoms of distress is the root cause. These are major concerns and in anxiety centre around issues of

1.       Control

2.       Competence

3.       Acceptance

What happens is that the anxiety around not being accepted, being in control or being competent can generate the opposite action where people attempt to be competent, in control and accepted at any cost. If the opposite isn’t achieved then depression can follow.

People’s major concerns can be embedded by lifestyle, so the jobs that people choose, their partners, their cognitive set and way of looking at the world.

The therapeutic aim here I guess is to loosen the original belief. The original belief needs to be pulled up and out and into awareness.  If the feeling is I’m inferior then I guess the work isn’t to dispute that as that is what the client tries to do with their inversion but rather to say ask is your identity purely tied up with your performance. Could you be loveable without having to perform.  In the case of acceptance then again it’s difficult as you need to say that you can be ok, without everyone accepting you. With control, you can be ok, without being in control. You can go back to look for the original time when this was created, the child who felt horribly out of control, if you can repeat this time so that the adult to come to terms with this that might help.  

Part of what they want, acceptance, control and competence is needed, but the absolute sense of I’m nothing without it needs to be challenged. I suppose you can also challenge it directly where the original fear gets buried, I’m incompetent, there can be evidence of both where you are competent, and also evidence of where making mistakes is useful or ok. Likewise with acceptance, then there can be both evidence where you are accepted and also where you aren’t and that’s ok. Same thing goes for control .

Book Summary

Anxiety is a feeling we want to get away from, it demands our attention, it speeds us up as it is insistent that it is paid attention to. Anxiety seems to be part of a system that enabled us to deal with physical danger.  Anxiety is the affective component with fear, fear being an evaluation that there is danger around. Often with anxiety the object of fear is not known but rather a situation or time provokes anxiety. In these times it could be because we have forgotten the object of fear, but have been frightened so often in these situations that the appraisal has been lost in the association of affect with situation. Possibly there has been stimulus generalisation, so the new object of fear is a generalisation from the original source and we are not aware of the relation.  It is also possible that we are afraid of the thought that provokes anxiety itself so we push it out of our awareness. Finally there is the possibility that an accumulation of aspects collectively result in a feeling of anxiety, so all of its constituent parts need to be isolated.

Anxiety seems paradoxical often as it decreases our ability to cope and therefore increases the danger.  The reason for this is that anxiety seems to have originated in response to physical danger. When anxiety strikes all we can think of is feared and dangerous situations, we can see ourselves not coping, our breathing, perception and cognitive faculties are all impaired. This can be useful in terms of physical danger. Anxiety can stop us performing a reckless act. It can make us freeze to give us more time to think and to be able to absorb blows if we are under current attack. Likewise fainting  can be useful to play dead, so as the enemy avoids you, or again to staunch any blood flow.  When it is used with psychological danger then it seems to make the danger worse, the person with social anxiety finds it hard to speak, the person taking the exam finds it hard to think, the person who fears loss of control becomes more out of control.

With anxiety disorders there are a couple of things that happen. Firstly there is a very high level of anxiety response where the danger is magnified and the ability to cope is minimised.

The first point that needs to be made with client is that the target for work with anxiety is not the feeling of anxiety itself but rather its causes.

Before you start on treatment its worth thinking about what the client thinks about anxiety to see if there are any meta feelings and thoughts that can contribute to feeling bad about having anxiety, these need to be dispelled before starting.

So with clients then first of all what needs to be established is what are they frightened of and why. If a client has anxiety without knowing why in a situation then you can look for other situations where they have similar feelings then find out what is in common between these. The other thing is to ask them for any thoughts that happen before the situation. Alternitavely then ask if they have any images that come to mind. If none of this works then look to get anxiety within the room then find out what they are thinking.

There are 3 main aspects of anxiety

1.       Competence

a.       This is where performance anxiety comes in. The base schema is that to be loved then I must be competent, therefore performance becomes a significant aspect to a persons identity.

2.       Control

a.       This is where fear of going mad comes in, being in control is central to a persons personality and anxiety is provoked where they feel out of control

3.       Acceptance

a.       This is where social anxiety can come in, where being part of the gang, accepted by the other is crucial to identity. Social anxiety can also tie up with competence, where there are a defined set of rules that must be adhered to to ensure social success, any deviation from these, provokes a feeling of shame, guilt and then anxiety

The response to anxiety are fight, flight, freeze of faint. If the danger is seen to be less than the clients resources then the fight response can be offered, if not then flight, freeze of faint is taken. The way anxiety comes is firstly there is the primary perception of finding something of interest to me which can either increase my values or decrease, fear is the reaction to the threat of something valuable being taken away

Once what the feared object\situation is then you need to use the downward arrow technique to find out what the base fear is. Given this being establish then you need to look at the coping mechanisms used, be it avoidance, or looking for someone externally to reduce the threat, or a magic ritual.

With the coping mechanism isolated then you need to do an ABC analysis to see what effect the coping mechanism has and what its effects are. Chances are it reduces anxiety, chances are that there are secondary gains that keep it in place. So isolate the reinforcers. This being done then work with the client to see how their coping mechanisms don’t challenge the underlying thought or schema of vulnerability and how the fear can be maintained by the reinforcers.

The other part of analysis of the feared situation is to do though records to see what the catastrophising thought is and how it can be challenged This will increase their coping resources. Likewise asking wheres the evidence can increase their coping resources as it will show them how they can reduce the perceived level of danger by their cognitions.

The next step is to get the client to have more control over the situation. To do this then they need to count the number of times that they are anxious. Doing this will firstly find out more about their anxiety what its scope and frequency are. Secondly in counting they will take some distance from it and therefore become an observer which will change the anxious reaction, it will also give them a greater feeling of control as they can at least count. When counting has been performed then you can get to increase their control over their anxiety by naming it, maybe even give it a character and refer to it in the third person. Having done this then you can increase their frustration tolerance by getting them to wait longer before resorting to their coping mechanisms.

Once the increase of mastery has happened then look to increase coping resources. You can do this by decatastrophising a situation, look to see if their worst fears took place  how would they cope

Now strengthening has happened, then you can start to think about exposure. Get them to created a graded hierarchy of feared situations. Teach them relaxation through breathing, meditation and progressive muscle relaxation. Get them to get into a state of relaxation and imagine themselves performing one of the items on the hierarchy. When they can do this successfully without excessive anxiety, then look to get them tpo think of a reinforcer to be conditional on success of each task. Then get them to perform each task in turn to increase their feelings of mastery. For each task then see it as an exercise

Techniques

1.       Images

a.       Repetition (flooding)

b.      Modifying image

c.       Replacing image

d.      Cartoonifying image

2.       Cognitions

a.       Thought records

b.      Acting as a role model

c.       Decatastrophising

3.       Actions

a.       Distraction

b.      Focussing on the other

c.       Graded task hierarchy, exposure

d.      Acting as if