Cognitive Therapy of Anxiety Disorders: Adrian Wells

Contents
Chapter 1 Cognitive Theory and models of anxiety: an introduction 5
Cognitive theory of anxiety disorders 5
Dysfunctional schema 5
Negative automatic thoughts, worries and obsessions 6
The role of behaviour 6
Chapter 2 Assessment: An Overview 6
Aims of assessment 6
Measurement 6
Depression 6
Anxiety 7
Panic disorder and agoraphobia 7
Health anxiety 7
Social Phobia 7
Generalised Anxiety 7
OCD 7
Cognitive Therapy assessment Interview 7
Detailed description of the presenting problem 7
Cross sectional cognitive behavioural analysis 7
Longitudinal analysis 8
Underlying assumptions and beliefs 8
Structure of the assessment interview 8
Multiple Presenting Problems 8
Chapter 3 Cognitive Therapy: Basic characteristics 8
Cognitive techniques 8
Behavioural techniques 8
The structure of therapy 8
Relapse prevention 9
Socratic dialogue 9
Chapter 4 Cognitive Therapy: Basic techniques 9
Eliciting NATS 9
Ten methods for accessing NATS 10
Reattribution Methods 11
Verbal Reattribution 11
Behavioural Reattribution 13
Chapter 5 Panic disorder 14
Characteristics of panic attacks 14
Cognitive model of panic 14
Selective attention 15
Safety behaviours 15
Avoidance 15
From cognitive model to case conceptualisation 15
Assessment 15
Deriving the vicious circle 15
Developing the basis formulation 15
Socialisation 15
Sample socialisation experiments 16
Reattribution Strategies 16
Behavioural strategies 16
Verbal Reattribution Techniques 18
Chapter 6 Hypochondriasis: Health Anxiety 19
A Cognitive model of hypochondriasis 20
Cognitive factors 20
Affect/physiological changes 20
Behavioural responses 21
General treatment issues 21
Engagement in treatment 21
From cognitive model to case conceptualisation 22
Socialisation 22
Reattribution Strategies 23
Behavioural experiments 23
Verbal reattribution techniques 24
Dealing with health risk behaviour 26
Conclusion 26
Chapter 7 Social Phobia 28
The nature of Social Phobia 28
A cognitive model of social phobia 28
Anticipatory and post-event processing 28
Processing of the self as a social object 28
Assumptions and beliefs 29
From cognitive model to case conceptualisation 29
Eliciting information for conceptualisation 29
Negative automatic thoughts 30
Anxiety symptoms 30
Eliciting contents of self-processing 30
Ask about imagery 30
Identifying safety behaviour 30
Socialisation 31
Selling self-processing 31
Behavioural experiments in socialisation 31
Sequencing of treatment interventions 31
Modifying self-processing 31
Verbal reattribution 32
The social balance sheet 32
Thinking errors 32
Using rational self-statements 32
Defining fears 32
Dealing with anticipatory processing and the post-mortem 33
Behavioural Experiments 33
Interrogating the environment 33
Overcoming avoidance 33
Working with conditional assumptions and beliefs 33
Conditional assumptions 33
Generating alternative evidence 33
Rigid rules 34
Unconditional negative self-beliefs 34
Positive data log 34
Interpersonal strategies 34
Summary 34
Chapter 8 Generalised Anxiety Disorder 34
The nature of worry 35
The nature of worry in GAD 35
A Cognitive model of GAD 35
Eliciting information for conceptualisation 36
Verbal strategies for eliciting type 2 worries 36
From Cognitive Model to Case Conceptualisation 37
Socialisation 37
Modifying Meta-Worry and negative beliefs 38
Verbal Reattribution 38
Behavioural Experiments 39
Modifying positive beliefs about worry 40
Mismatch strategies 40
Worry abandonment experiments 40
Modifying Cognitive bias 40
Strategy shifts 41
New endings for old worries 41
Letting go of worries 41
Avoidance 41
The problem of co-morbidity 41
Chapter 9 OCD 41
Cognitive models of OCD 41
The Salkovskis model 41
Wells meta-cognitive model 41
Attentional strategies 42
A general working model 42
Maintenance 42
Developing a case formulation 43
Symptom profile and triggering influences 43
Eliciting dysfunctional appraisals 43
Socialisation 44
General aims of cognitive therapy 44
Verbal reattribution 44
Defining the cognitive target and detached mindfulness 44
DTR in OCD 44
Thought action defusion 44
Thought event defusion 45
Identify Images 45
Behavioural reattribution 45
ERP: the behavioural perspective 45
ERP a cognitive reconceptualization 45
Challenging specific beliefs 46
Response prevention: contamination fears 46
Absence of cognition 46
Additional considerations 46

Chapter 1 Cognitive Theory and models of anxiety: an introduction

Wells uses a Beckian approach, so comes from a cognitivist stance.  The main premise being that client’s distress arise from a dysfunctional interpretation of events and not the events themselves.  Behavioural responses that arise from these interpretations have a maintaining factor in their distress.

Ellis sees that should, musts, commands and demands lead to illogical cognitions and emotional disturbances.

Beck sees anxiety as accompanied by distortions in thinking and a stream of negative automatic thoughts in the patient’s consciousness which reflect the underlying activated schema.

Cognitive theory of anxiety disorders

In anxiety disorders there is a fixation on the concept of danger and the inability of the client to cope. The problem with the anxiety disorders is not in the affective response but in the cognitive processes which interpret danger everywhere and then produce the affect. Likewise in the cognitive process that drives the avoidant behaviour that reinforces the idea that there is something to be scared about.  There is a vicious cycle that gets created which include the anxiety symptoms which may themselves pose a threat. They can impair performance and be interpreted as a sign of vulnerability.

Dysfunctional schema

Beck sees two types of cognition within a schema they are beliefs and assumptions. Beliefs are unconditional and are taken as truths about the self and the world. Assumptions are conditional and are the interface between events and self-appraisal, if I show signs of anxiety then people will think I’m weak.

Maladaptive schemas are usually seen as being as more rigid and inflexible than adaptive schemas.  GAD has a belief around inability to cope and the positive and negative beliefs about worrying. Panic patients tend to misinterpret bodily symptoms catastrophically.

The beliefs can develop in childhood or can develop in response to later year’s events.

Assumptions or rules lead a client to behave in certain ways, if I believe showing anxiety will mean people will think I’m weak, then I better say little to avoid this.

Negative automatic thoughts, worries and obsessions

NAT’s are appraisals of events and can be tied to a particular behavioural or affective response.  Beck describe NATS are rapid and can occur outside of the focus of immediate awareness, although they are amenable to consciousness.

Worry is a negatively affect laden thought chain aimed at problem solving. NATs can occur in verbal and image forms.

The role of behaviour

When there is an appraisal of danger, then the cognitive system facilitates caution by a series of self-doubt, negative evaluations and negative predictions. The somatic manifestation consists of a range of feelings such as unsteadiness, faintness and weakness. The effect of this according to Beck is to terminate risk taking and to orient the self towards self-protection.  In some areas e.g. social phobia this response mechanism actually increase the danger that is faced.

The difficulty that these automatic anxiety responses have for clients is that they maintain preoccupation with the fear and also prevents its disconfirmation of dysfunctional thoughts and assumptions.

Chapter 2 Assessment: An Overview

Structured Diagnostic interview aims to establish a specific diagnosis. A Clinical assessment is a semi structured interview that does not aim at a diagnosis.

Aims of assessment

·         Identification of problem

·         Elicitation of information for case conceptualisation

·         Determination of present and past levels of client functioning

·         Objectification of presenting problems, e.g. core scores.

·         Determine specific goals

o   Therapy goals e.g. reduce panic attacks

o   Process goals, e.g. do cognitive restructuring

Measurement

Depression

·         BDI

·         Hopelessness scale (HS)

Anxiety

·         BAI

·          State-Trait Anxiety Inventory (STAI)

·         Fear Questionnaire

Panic disorder and agoraphobia

·         Agoraphobic Cognitions Questionnaire (ACQ)

Health anxiety

·          Symptom interpretation questionnaire (SIQ)

·         Illness Attitude Scale (IAS)

·         Health Anxiety Questionnaire (HAQ)

Social Phobia

·         Fear of negative evaluation(FNE)

·         Social avoidance and distress (SAD)

·         Social Interaction Anxiety Scale (SIAS)

·         Social Phobia Scale(SPS)

Generalised Anxiety

·         Anxious Thoughts inventory (AnTI)

·         Meta Cognitions Questionnaire (MCQ)

OCD

·         Maudsley Obsessive Compulsive Inventory (MOCI)

·         Padua Inventory (PI)

Cognitive Therapy assessment Interview

3 Aspects

1.       Detailed description of the presenting problem

2.       Analysis of cross-section symptom, cognitive and behavioural details

3.       Longitudinal assessment

Detailed description of the presenting problem

Get SETB information and get a baseline score of frequency and intensity. Look at the behaviours used to manage the problem.

Cross sectional cognitive behavioural analysis

Look at the maintaining factors, the modulators. Do an ABC of the problem.

A= Antecedents or triggers, internal or external, so signing a name in public, or heart racing

B=Beliefs, appraisal of trigger

C=Emotional and behavioural responses, behaviour can be avoidance

Longitudinal analysis

Elicit historical data that has increased a client’s vulnerability to the problem, also look to how they have coped with it in the past.

Underlying assumptions and beliefs

To do a formulation then you need the underlying assumptions and beliefs.

Structure of the assessment interview

1.       Review objective measures

2.       Explain the structure and the goal of assessment

3.       Ask patient to describe problem

4.       Determine cross sectional analysis, do an ABC

5.       Determine longitudinal analysis

a.       Critical incidents

b.      things you learnt from the past that contribute

6.       Feedback

Multiple Presenting Problems

Get problem list and prioritise. Determine any interrelationships between the problems.

Chapter 3 Cognitive Therapy: Basic characteristics

Cognitive therapy is conceptually driven that accords to the case conceptualisation. Socratic questioning both uncovers beliefs and also challenges them.

Cognitive techniques

CT is concerned with uncovering and challenging dysfunctional thoughts and beliefs.  This is done by Socratic questioning, CBA, behavioural experiments, exposure, role play, continuum techniques

Behavioural techniques

Some behavioural strategies aim at modifying symptoms directly e.g. relaxation and distraction techniques but their key to use is to change the belief at the NAT and schema level.  Behavioural approaches are exposure experiments, min survey, activity monitoring and scheduling, manipulation of safety behaviour and attentional focus.

The structure of therapy

Initial sessions=Focus on alliance, socialisation, assessment and conceptualisation

Middle phase=treatment planning, implementation, symptom reduction

End phase=symptom vulnerability treated,  consolidation and relapse prevention

The same techniques for modifying NATs can be applied to schema.

Relapse prevention

1.       Check residual NATs

2.       Escape hatch routines

3.       Check any dysfunctional behaviour

Silly to say but CBT aims at the modification of the variables of cognition and behaviour, that is all! To do this you need to unearth the thoughts, rules and core beliefs at play and to see what is the full detail of behaviours, if you fully understand reinforcement you can think about substitution.

A problem list gives a list of what is wrong. A goal is detail of what the client would like to happen. To make a goal concrete it needs to be described in observable terms.

Socratic dialogue

1.       Ask a question that the patient can respond to

2.       Questions open up subject areas

3.       The patient shouldn’t feel interrogated

4.       The therapist should genuinely attempt to understand the clients experience

General questions can often be combined with probe questions, so what did you feel in that situation, is a general question, when you felt scared what went through your mind is a probe question. Again it can be nice with questioning to include an aspect of summarising as well, so when you felt (what you have just told me) how did you feel

General questions open up areas, probe questions get more detail and often search for worst scenarios or the appraised consequence of not coping.

Open questions are what, where, when and how, why is as well but can be answered with I don’t know. You can ask a why question with for what reason. 

You can avoid creating a feeling of interrogation but good pacing and summary.

Chapter 4 Cognitive Therapy: Basic techniques

Eliciting NATS

Important to distinguish between primary NATS and secondary thoughts. In anxiety primary thoughts concern themes of danger and fear and secondary thoughts concern themes of escape, avoidance. To elicit the primary NAT then you should look at what the feared consequence of not engaging in the secondary behaviour.  There are other thoughts the clients mentioned which could be seen to be surface thoughts. This is where the thought is related to the NAT but its relation is obscure, for example I thought I was going to panic.  NATs are different to the content of worry or intrusive thoughts, rather it is the NAT about the worry or intrusive thought.

Ten methods for accessing NATS

1.       Worst case scenario

a.       What’s the worst that could happen if (coping behaviours weren’t done, to the surface thought). It can also be useful if a client can’t access a thought, but rather just a feeling. So then the question would be what were you most aware about. Say emotions and behaviours, and you could say what’s the worst that can happen

2.       Recounting specific episodes

a.       Determine emotional symptom first, then the accompanying NAT.  If you get a secondary thought then ask did you think anything bad could happen if you didn’t do your safety behaviour.  If NATs are not coming then eliciting of the emotions involved in the situation can help them access the NATs.

3.       Affect shifts

a.       Sometimes when avoidance is high, then there isn’t a recent occasion, in this instance affect shifts give indicators that there are NATs are present.  Some clients are affective avoidance, cognitive affective avoidance is shown by a tendency to discuss situations in fine details.

4.       DTRs

5.       Exposure tasks

a.       AS fear is activated then NATS will be present so that you can use exposure to gain NATs. Often when the feeling isn’t evoked, then the NAT isn’t so in high affective state these become accessible.  So for social phobic exposure, then questions like how do you think you seem to get an understanding of what they thought others were thinking.

6.       Role plays

a.       Here the aim is to get the client to indicate an increase in affect and at this point investigate the NAT

7.       Audio\Video feedback

a.       Record the client then play it back with the client, when they show or indicate an affect shift then stop the tape and investigate the NAT. This technique is useful when you can’t break in, seamlessly into a situation. It is also useful when the affect itself may be overwhelming

8.       Manipulation of safety behaviours

a.       Reducing safety behaviours will expose to fear and make negative thoughts more obvious. Sometimes you can decrease safety behaviours which will increase fear, sometimes you can increase safety behaviours which will make symptoms worse and bring up NATs. This can work well with misinterpretations of bodily sensations

9.       Symptom induction

a.       Behaviourally you can get someone to a panic state by hyperventilation. Cognitively you can bring someone’s intrusive thought to them and see how they respond. If they refuse, you can find out the NAT by asking them what the worst that could happen if they had the thought or bodily sensation

10.   Ask about imagery

a.       It NATs are difficult to get then ask about any disturbing images.

Reattribution Methods

Durable modification of NATs requires changing the range of variables for their maintenance at schema level

Verbal Reattribution

Operationalise

First of all you need to operationalize to find out what the meaning of the NAT is. Indeed it might be secondary, I have to get away, against a primary NAT of something’s scary.

To operationalize

1.       What does that mean

2.       What would it look life if…

3.       Downward arrow

4.       If you could do x how would things be different

Questioning the evidence

Once you get the evidence then you can reframe, look for alternative explanations and generally weaken the NAT. You can also look for thought errors.

1.       Where’s your evidence x will happen

2.       What makes you think that

3.       How do you know that it will happen

4.       What is your reason for believing that

Reviewing counter evidence

1.       What’s the evidence against x

2.       What’s another way of looking at the problem

3.       Where’s the evidence to support an alternative view

4.       If the worst hasn’t happened why not?

5.       What’s the worst that could happen, what’s the best that could happen, what’s the most likely

The aim of reattribution is to modify the belief in the consequences, meanings and implications of distress. So I feel anxious, what’s the worst that could happen. So instead of challenging I will panic, find out what would be so bad if you did. This will contain the real fear rather than the panic and will contain the areas that can be changed.

Labelling distortions

So identify the thinking error in the NAT. You will need to educate a client in terms of why a thinking error is dysfunctional, once you do that you can label it and reuse it.

Use of rational responses

After DTR’s, questioning the evidence and use of thinking errors this should produce a rational response. These can be written on flash cards and brought to mind when the original dysfunctional thought it had. This could become a safety behaviour so caution should be exercised.

Cost Benefit Analysis

Two aims

1.       Increase patient motivation

2.       Elicit beliefs and assumptions

Rate the levels of belief in each statement and award significance points, i.e. you may have only one item but it might be very powerful

Wells 73

Pie Charts

Standardly used to reduce percentage of belief in responsibility and catastrophic outcome. So get the list of possibilities, then start with the most benign one and ask how much this could explain x.

Start with the belief beforehand do the pie chart and then the belief afterwards

Education

When client’s information is inaccurate, then you can use education.  This can mean internet research from reputable sites, books and hand-outs, maybe even surveys. To do this effectively find the inaccurate belief, rate its belief, use education then rerate this belief.

Continuous presentation of the model

This means both the cognitive triangle as well as the formulation. This will reattribute the patient as it will understand their problem in a different light.

Point and counter point

Here the client takes their dysfunctional belief and argues against you, then you reverse roles.  Both people speak in the first person. Again rate belief for and belief afterwards.

Imagery techniques

Explore the meaning of the image. If the image stops prematurely then roll it forward to its conclusion, this technique finishing out can be powerful as the client may well stop at the worst point.  You can also use image modification, so for instance introduce a best friend or caring adult. This is rescripting I think

Action plans

This means identifying new skills that are needed and practicing them then making a plan to put them into action.  They can then be role played or rehearsed in memory to debug any tricky situations. Prime to relapse prevention is getting action plans for difficult situations.

Finish 78

Behavioural Reattribution

Use of exposure in CT

Can be used to challenge NATs and Core beliefs. Can be exposing to external or internal events.

Behavioural experiments

3 aims:

1.       Socialise

a.       So increase safety behaviours and increase distress!

2.       Reattribution

a.       They can be reality testing

3.       Modification of affect

a.       Distraction, activity schedules can provide temporary relief and can break the cycle of distress. Activity scheduling can show how relief from NATs can improve mood.

Designing and implementing effective experiments

1.       Identify key target cognition

2.       Second key cognitions need to be operationalized

3.       Therapist and client decide which variables are to be manipulated to test the belief. Do this by examining the patient’s avoidance and safety behaviours.

4.       The belief must be rated

There are two aspects of an experiment, exposure and disconfirmatory manoeuvre to unambiguously test a belief.

Stage 1. Elicit the belief, find out the evidence and challenge to loosen it up for experiment

Stage 2.  Identify situations that elicit anxiety and identify behaviours that prevent disconfirmation

Stage 3. Share the rationale for the experiment with the client.

Stage 4. Expose and have the client do the disconfirmatory move

Stage 5. Discuss the results

So PETS is the way to do experiments

Prepare, Expose, Test  and Summarise

The best way to find the patients disconfirmatory manoeuvres is to ask them what they do to prevent their feared outcome from coming true.

Schema focused techniques in anxiety disorders

Schema work should be done after work on NATs and intermediate beliefs and also after symptoms have been reduced. When doing downward arrow, then if that were true what would it say about you, if that were to happen. When you look at Meta cognitive beliefs, or type 2 worries, then you would do a downward arrow about having the belief. So to do a Meta downward arrow, what’s so bad about having that thought?

Imagery and schemas

Ask for the meaning of the image. Elicit it if it’s been reported, then once you have the meaning do the downward arrow.

Restructuring of rules, assumptions and beliefs

You can write out the downward arrow with its various stages and challenge each stage,  you can identify the thinking errors in each stage, or the move between stages.

Beliefs and assumptions guide interpretation of events and influence behaviours and emotions. Some beliefs we learn from early childhood and are not helpful to us anymore. Schemas often contain dichotomous thinking so continuum work is useful to approach them.

Chapter 5 Panic disorder

Characteristics of panic attacks

Panic attacks are described as rapid escalations of anxiety where there are at least four of the 13 symptoms from the DSM categorisation, these four or more have to escalate within a ten minute period to be classified as a panic attack.  These symptoms include palpitations, derealisation, sweating and shaking.  Panics can either be situational, i.e. cued or spontaneous.  To be classified as panic attacks then you need at least two spontaneous attacks.  Panic attacks happen in other disorders such as social phobia.

Panic attacks can happen nocturnally in which case the client may wake in a state of acute anxiety. Panic common occurs with agoraphobia.

Cognitive model of panic

Clark\Beck state panic is the client’s fear of certain bodily or mental events, so stimulus, internal\external are appraised as threatening and produce anxiety, this in turn leads to physical\cognitive symptoms that are misinterpreted as threatening and in turn produce more anxiety. The panic is then maintained increased attention to the body and signs of panic, heightened self-attention focussing, avoidance and other safety behaviours.

Selective attention

When you concentrate your attention on certain parts of your body then they start to feel strange.  It also increases your sensitivity to bodily change.

Safety behaviours

These prevent disconfirmation of the misinterpretation, e.g. holding onto a table as you think you might faint.

Avoidance

This also prevents disconfirmation what it also does is to strengthen the dysfunctional belief, as they are reminded about its truth every time they avoid something

From cognitive model to case conceptualisation

Assessment

This seeks to understand the pieces of the model, what is the threat, what are the physical\cognitive symptoms what are the safety behaviours and what is the misinterpretation. So the Clark model is a simple model that can then be extended by the inclusion of core beliefs which might explain some of the misinterpretations

Deriving the vicious circle

Go through a panic incident in slow motions: Felt unreal (trigger) => What if I panic (Misinterpretation) =>Anxiety=>heart racing (physical symptoms) =>I’m having a heart attack (misinterpretation

Developing the basis formulation

Whilst there are obvious avoidances there may be more subtle ones, so ask are there any situations that you avoid because of your anxiety.

With safety behaviours then ask are there any things you do to protect yourself against anxiety generally and then specifically within a specific panic incident.  When you have safety behaviours then ask how likely it was the feared occurrence would have happened if the safety behaviours hadn’t been performed.

Socialisation

First build the panic model and ask the client if it fits and if not why not. Again you can psychoeducate with the rush of adrenalin that is received from belief of catastrophe, that can cause anxiety.

Sample socialisation experiments

Paired associates

So get the client to note down their anxiety, then to read word pairs e.g. breathless and suffocate, then get them to dwell on each pair for 30secs then at the end get them to rate their anxiety, this doesn’t always work but sometimes it does and that being the case then you can strengthen the link between thoughts and emotions. If it doesn’t which in many cases it won’t then you just say that it was an experiment to test cognitive sensitivity.

Body focus

Show how selective attention can increase the awareness of bodily sensations and how it can enhance them, so get them to concentrate on their finger. You can also do this with vision, i.e. stare at the back of your hand and say what happens to the vision and what happens to a feeling of unreality

Increased safety behaviours tests

Safety behaviours can be manipulated in session to show the maintaining and enhancing effect of safety behaviours.  So if deep breathing is used to prevent a panic attack, then get the client to deep breathe to see what effects it produces.  Whilst when in a panic situation they probably don’t breathe as heavily as they might do in session, when they are having a panic they are a lot more sensitive so smaller changes will be magnified.

Metaphors and allegories as socialisation

To illustrate the fact that safety behaviours prevent disconfirmation, then you can use the allegory of the tribe that do a special ceremony every year to keep the world spinning, if you tell them that’s silly they say look its worked, how can you show them.  So can you discover that nothing bad is going to happen if you drop your safety behaviours?

If you are going to see safety behaviours aren’t needed then you need to get the patient to push their symptoms during an attack and not use safety behaviours.

Reattribution Strategies

Socialisation is important to provide a cognitive set which enables the processing of disconfirmatory experiences. The key to CT with panic attacks is to prevent the avoidance and safety behaviours that prevent disconfirmatory experiences. The key element then is to reduce the belief in misinterpretations and block avoidance so the feedback cycle that blocks disconfirmation needs to be broken.

Behavioural strategies

Many of these experiments are panic inductions and are aiming to challenge misinterpretations.

Guidelines for effective symptom induction experiments

When you provoke panic, you should get as close to the symptoms experienced in the real panic attack.  The closer these symptoms are then the greater the reattribution that will happen.  So what you need to do is to be clear on what symptoms the patient has, and what their safety behaviours are to ensure they don’t do them. You then need their belief what would happen if they don’t use their safety behaviours, then challenge this with the experiment.

The experiment might be weakened by the presence of the therapist as a rescue factor, so in this case they might need to be out of the room when the panic induction happens. Likewise some subtle safety behaviour might be  used during the panic induction which needs

Hyperventilation provocation task

Use this to produce

1.       Dissociation

2.       Sweating

3.       Palpitations

4.       Breathlessness

So this task is useful in challenging beliefs of, I’m going to have a panic attack, or go mad. Get them to stand up, you can use disconfirmatory approaches, to show they aren’t going to fall over, by getting them to walk in a straight line on one leg.  You can also use a bright light while hyperventilating to produce visual anomalies and unreality. Do this for four minutes.  Follow this with a text reading exercise to show that vision hasn’t been impaired.  I suppose really the disconfirmation is around the going mad if I don’t do my safety behaviours.  Again you can get someone to think crazy thoughts when they’re having a panic induction to see if they can force it to happen.

Hyperventilating can’t lead to fainting.  Fainting only occurs when there is low blood pressure, although in rare case of needle phobia it can occur. You can prevent this with the blood phobia through using applied tension during exposure.  You should not do forced hyperventilation when the following medical conditions are present

1.       Asthma

2.       High blood pressure

3.       Pregnancy

Physical exercise tasks

Useful where the concern is about heart rate and concerns about physical robustness

Chest pain strategies

You can create chest pain by get the patient to fill their lungs then breathe around full lungs without letting all the air out and after a few minutes discomfort is likely Again you can take a deep breath and push a finger between the rib around the heart region slightly to the side of the sternum, this can give a stabbing pain.  You really need to do this in conjunction with psychoeducation about chest pain, and about possible causes, through repeated deep breathing and strain on the thoracic musculature, alternatively the chest if full of delicate muscles which can become tense when anxious and give rise to chest pain.

Strategies for inducing visual disturbances

Staring at visual girds of black and white will produce visual anomalies.  So when the patient panics if they stare intently on something they would produce these experiences. Key here is being able to reproduce their panic feelings

Dissociative experiences

You can get these with hyperventilation or staring at a grid.

Acting as if experiments

Sometimes there are consequence of panic that are the problem, such as falling over and how people might react. In this case model it, then get the client to do it.

Verbal Reattribution Techniques

You must understand the exact nature of the feared catastrophe and the evidence on which it is based. If there is evidence then do a detailed analysis as it will quite often be the case say with fainting that they voluntarily sat down rather than fainted.

Questioning the evidence

Useful to use prior to the experiment.  So why hasn’t your catastrophe happened yet. It is useful to not that reality testing is often someone panicking can’t do so well, so you can get logical agreement outside the panic but not inside.  Thus it’s important to conduct experiments to provoke the anxiety, the panic to help with this ability.

The panic cognitions diary

The panic diary contains when the panic was, what the misinterpretations were and the behavioural answers to the misinterpretation.  Patterns in panics can challenge the organic nature that people see as the root of panics. The answer to the negative thought is only filled in after there has been some behavioural work to show a disconfirmation.

Education and exploring counter evidence

Patient may believe anxiety can kill, cause insanity or lead to fainting, but low blood pressure leads to fainting and anxiety increases blood pressure.  Patient may believe they will suffocate through stopping breathing but breathing is automatic, but becomes harder if you try to control it.  To challenge people have heart attacks because of anxiety, then how come as many people with anxiety don’t die of heart attacks, why wouldn’t British heart foundation advertise it, because its only people with heart problems that have difficulties like this.  Anxiety produces adrenalin, but adrenalin is used to get the heart started again.

Counter evidence against stroke

Strokes are caused by blood clots starving the brain of oxygen, but anxiety doesn’t cause blood clots

Counter evidence against panic sending you mad

Anxiety is there to help us respond to fear, and will allow us to freeze or play dead.

Counter Evidence

Could die of a panic attack	Have you ever heard of this
Could have a heart attack	Adrenaline in panic attacks is used to start hearts when people have heart attacks
Die of anxiety	Soldiers don’t die of anxiety
Anxiety increases blood pressure and weakens the heart	Temporary increases of blood pressure are similar to when you play sport but the only problem with this is when the increase is prolonged

 

Symptom contrast

Get the client to say what the symptoms of panic are and what the symptoms of fainting are and compare them.

Fainting	Panic
Everything goes black	Things seem fuzzy and blurred
Felt sleepy	Weakness in legs
Things slowed down	Heart racing
Felt warm	Felt warm
	Dry mouth

Survey Techniques

Do a survey with the panic symptoms and make sure you tightly specify the question

Dealing with avoidance

As soon as you see this in the client then you need to move on it with ERP.

Prognosis

Finding out how distressing a future panic attack would be gives a good guide as to what remaining work needs to be done

Chapter 6 Hypochondriasis: Health Anxiety

Whilst the DSM sees this as a somataform distress, it is anxiety about health and can be treated under the anxiety umbrella.  This treatment looks at Salkovskis’ model.

Central feature is the belief that you have a disease on the basis of a misinterpretation of bodily symptoms.  To be a DSM category it has to be present for 6 months and cause significant distress, the belief isn’t of delusional intensity. There is frequent reassurance seeking from doctors.  Hypochondriacs tend to react with immediate effect from a doctor reassurance but it only lasts a couple of days.

A Cognitive model of hypochondriasis

The main distress is from the misinterpretation of bodily symptoms. Huge similarity with panic, but panic sees the disaster as immediate, the hypochondriac, sees it as coming in the future.  Hypochondriasis tends to get activated due to trigger situations that activate health schemas

Salkovskis model

Previous experience

Dysfunctional schemas formed

Critical Incident

Activates schemas

NATS

Cognitive                                             Emotion                               Behaviour

Selective attention                          Depression                         Reassurance seeking

Worry                                   Anxiety                                                Avoidance: Bodily checking

Self-focus                                            Anger                                    Safety\Prevention         

Thinking errors

Physiological changes

Increased arousal

Bodily sensations

Sleep disturbance

The NATs are quite often in the form of images of the body giving out

Cognitive factors

You get selective attention and hypervigilance on specific parts of the body and on the excreta of the body. Also you get selective attention for negative health stories in the media, in the consulting room. Worry will also be a thought process type as an outcome of hypervigilance. Common cognitive distortions are discounting of alternatives, selective abstraction and catastrophising.

Affect/physiological changes

The affective response to misinterpretations is usually anxiety and these symptoms get mistaken for a symptom of ill health.

Behavioural responses

The maintaining behavioural factors are

1.       Checking

a.       Makes the client more sensitive to change

b.      Can create a bodily problem, e.g. soreness

c.       Continually tells them to worry about the possibility of their core belief coming true

2.       Avoidance

a.       Certain physical activities

b.      Thought control of illness thoughts

3.       Safety behaviours

a.       Taking supplements and things to ward of the illness

b.      Excessive resting

c.       Adopting certain body positions, or controlling certain bodily functions, e.g. swallowing, breathing etc.

4.       Reassurance seeking

a.       From doctors, friends etc., either overtly have I problem, or talking about symptoms

b.      Reading medical books

Some of the negative implications of illness are

1.       I won’t be able to work, where work is important to self-image

2.       I won’t be able to look after myself

3.       I will die but still be conscious

General treatment issues

The precise aim of treatment is not only to challenge the patients’ belief that they are ill but to offer an alternative credible explanation. Thus to socialise to the model is to move their frame of reference from the disease model.  With panic you can expose and show they don’t go mad or faint. With hypochondriasis you can’t expose them to their symptoms and show they don’t have cancer, rather what you do is to do experiments to strengthen the cognitive model.

Engagement in treatment

Treatment can be difficult when the patient has negative attitudes to health professionals. Indeed a client may engage as they just want to show they haven’t got a psychological problem rather a physical one.

How to manage this:

1.       Present therapy as a nothing to lose opportunity to discover what the problem may be. If their current strategies have been unfruitful, then an alternative maybe useful. Likewise you could just treat the anxiety, and then sell it on the basis of you can make better decisions when not anxious and look after your health better.

2.       Challenge patients erroneous perception means that psychological means it’s all in the mind, whereas their symptoms are real.

3.       Enter treatment with an open mind

4.       Shift the patients focus from signs and symptoms to emotions and misinterpretations

5.       Say that GP’s will treat them better if they have ruled out psychological approaches, if their relationship with their GP has broken down

From cognitive model to case conceptualisation

If panic is with hypochondriasis conceptualise and treat this first.

Panic=Trigger=>misinterpretation=>anxiety=>bodily symptoms=>safety behaviours & safety behaviours=>misinterpretation

After that conceptualise either using the standard Salkovskis model above or an idiosyncratic one that has the maintaining cognitive and behavioural aspects and the physiology, go via a current incident and ask questions that pertain to the varies aspects of the formulation.

With big emotions when you want to stay on track, say its ok, take your time, I can see this is upsetting for you, but... Hypochondriacs can have superstation’s that protect them from ill health.

Socialisation

Socialising is so important with hypochondriasis as the client strongly believes a physical explanation but you want to peddle a psychological one.  Behavioural experiments are important as they have a strongly physical element.  If they have panic then it can help to begin socialising and conceptualising with this.

Sample socialisation experiments

Treatment depends on building a credible alternative model to the one that they have

Tracking symptoms patterns

Patterns when you monitor may well be present, which can be used to challenge the disease based model. When you see  a pattern firstly ask why if it was a physical disease they would have this, and if there are any alternative explanations such as low blood sugar, alcohol withdrawal and stress.

Other questions to elicit patterns

1.       What happens to your symptoms when the doctor tells you they are not serious

2.       If reassurance makes you feel better, would this be the case if it was a physical disease

The ‘intelligent disease’ metaphor

If reassurance works how would the brain tumour know that it’s being reassured. If there are no patterns and reassurance doesn’t decrease the symptoms then look for places that increase symptoms such as medical programmes. If this was the case does the tumour have a brain to be able to respond to new information coming in?

Selective attention experiments

Do a self-attention focussed experiment on a body part that is known to be normal.

1.       Does it make you more sensitive to how the body part is

2.       Does it crease new sensations when you pay attention to it

You can also do other attention focused tests, when going bald =cancer, then look at bald people and establish if they think they have cancer.

Reattribution Strategies

Cognitive restructuring can fail when there are strong beliefs in the physical cause of their distress, so the move is to move away from looking for signs and symptoms to thoughts and behaviours.  Cognitive restructuring can be used but really only as a loosening of beliefs, which then needs to be augmented with behavioural experiments to support the cognitive model.

Behavioural experiments

Testing patient predictions

With their avoidant behaviours then you can get a prediction to test, in what would happen if you didn’t avoid.

Survey methods

Ask others if they have similar symptoms and what they make of them

Paradoxical procedures

So increase safety behaviours and see what happens, if it makes the symptoms worse, then if you decrease them, or eliminate them then they will make them better.

Medical consultation during CT

It is important to know that they do not have a physical illness, but you will want to get them to suspend any medical tests during the course of CT.  If they refuse, or have tests booked, then use these to establish how their symptoms change in the light of reassurance.

Reducing reassurance seeking

Look at the clients’ behaviour, how they seek reassurance from a variety of sources and get conflicting information which then fuels their thoughts that doctors are incompetent, which then means they search out a new one, when it was the sense of ambiguity that was the cause of the problem.  A CBA should be drawn up for repeated reassurance seeking.

Developing a plan for medical consultation

Encourage clients to develop a diary and to not to recheck their problem for a week, if their problems are still a concern then they may decide to seek consultation.  The client should move towards developing a blueprint of when to seek consultation, i.e. have they waited a week, have they consulted on it before and symptom persistence.

Self-monitoring

As much as symptom monitoring is useful then monitoring other variables is important e.g.

1.       Caffeine

2.       Alcohol

3.       Sleep quality

4.       Stress levels

Once this is done chart it back to when the symptoms seem worse to see if you can see any connection.

Verbal reattribution techniques

Some hypochondriacs will take all session describing in detail their symptoms seeking reassurance if they do or don’t have an illness, this will derail therapy and they should be challenged as to what the benefit of doing therapy like that is.  It should also be explored. One assumption that there is is that the therapist should know everything about their symptoms to be able to assess their cause, or that health professionals miss details so given the opportunity to talk, it will be done in detail

The standard therapeutic drift is away from negative appraisals and assumptions on to symptoms and signs.  To correct this elicit the meaning of client’s thoughts and meaning of thoughts when they are preoccupied with health anxiety.

The health anxiety thought record

Modifying the standard DTR is useful by dropping the evidence for column which would be excessive and adding one for the trigger for health anxiety.  Again adding a response to thought column is useful, so what did they do about it, what was their rational response?

Pie Charts

Health anxiety people overestimate of there being serious causes of sign and symptoms.  It is best to do this after some loosening work, say attention on finger, looking for patterns etc.  To do the pie chart then list the individual reasons first, then give them percentages most benign first.

Inverted pyramid

This is closely related to the pie chart and intended to demonstrate a tendency to catastrophisation, again best done after some loosening work has been done.

Start with how many people in your city have the same symptoms

How many still have the symptom at the end of the day

How many people still have the symptom the next day?

And after 3 days

How many people would test their symptoms?

How many people would it be found have something serious?

How many people are told it’s what you are frightened of?

Thinking errors

In the context of the pie chart and the pyramid procedures, then there is identification of thinking errors, catastrophisation, selective abstraction and black and white thinking.  In cases like this it can be useful to bring out the thinking error, label it and ask the client to look for other times that they do it.

Answering thoughts and image modification

The labelling of thinking errors can be used as an initial step before doing DTRs and image modification.  The therapist can show how images can have effects by checking their suds level, then getting an image that is anxiety making for them, although not in health anxiety, getting them to do it and note the response.  Patients typically block or suppress their image before they reach the worst point. Again they may block the cognitive significance of the image or the image entirely for fear that they will make it come true.

If images are suppressed then a two stage approach is required.

1.       Say how blocking it, keeps the fear active as you can’t challenge the image or the meaning attached to it

2.       Question the evidence of the content of the image and present corrective information.

This corrective information may then be included into the image such that when it occurs then the image can run to its natural conclusion.

The dual model strategy

Draw two columns, one evidence that my problem is physical, one evidence that my problem is psychological, or better stated, Evidence that my problem is: I have a heart problem, belief that I have a heart problem. In the evidence for the heart problem then each item should be reframed.

Dealing with rumination and worry

Some hypochondriacs have long periods of worry in that they may spend long time thinking about alternative causes of their symptoms and if the worst is true the implications of this. These worries may because of positive beliefs about worry, in that if they don’t worry it will lead to catastrophe, or if they worry they avoid some punishment from god. Conversely if they think positively it might tempt fate.  Likewise they believe that worrying will prepare them giving them early warning signs for the disease and therefore preventing it.  You can do some experiments around the thought that thinking positively will cause problems, by getting them to do it and see what happens.  Likewise you can CR through thinking about how the causal mechanisms from thought to illness might take place. 

You can then look at the advantages and disadvantages of worrying.  Again you can use general GAD approaches, maybe the worry tree, checking problem orientation, positive beliefs about worry and intolerance of uncertainty.

Modifying assumptions and beliefs.

There are some assumptions around health anxiety

1.       Punishment from god

2.       Costs of illness such that a family wouldn’t cope

3.       Loss of respect from others

4.       Existence after death

5.       My body must be symmetrical

6.       Any change in the body is a sign of aging

7.       Stress and anxiety can damage a body

8.       Things in the past have damaged my body

Metaphysical beliefs are not amenable to behavioural experiments so should be approached with dissonance induction in Socratic questioning. 

BTW:Worms are vegetarian, bodies decompose through bacteria

Imagery techniques

Three levels of intervention

1.       Events portrayed in the image can be modified at the NATS level

2.       Meaning of having images can be altered

3.       Images can be used to gain access to beliefs and manipulated to change belief.

If an image is seen as a sign of something, then this can be challenged.

If an image stops before its worst point then it should be rolled forward to after the worst point, i.e. finishing out.

You can also rescript the image, so get relatives laughing at the funeral

Dealing with health risk behaviour

Sometimes health anxiety patients continue with potentially damaging behaviour e.g. smoking which can be taken as evidence that premature death is likely. One goal of therapy can be to reduce these risky behaviours.  This can help redefine the client as a strong healthy person

Conclusion

The main work is around decatstrophising the feared outcome, looking for how the health anxiety is maintained, working with the core beliefs of vulnerability and changing the catastrophic misinterpretation of symptoms.

Chapter 7 Social Phobia

The nature of Social Phobia

Social Phobia is the fear of negative evaluation for some failed performance. The negative evaluation leads to social rejection and loss of self-worth.

DSM 4 Social Phobia is a marked and persistent fear of social\performance situations where embarrassment may occur.  For diagnosis to happen, then the social situation must more than provoke a feeling of dread or a desire to avoid, and this must significantly impair a person’s functioning.

SPCs are worried that they will be seen as weak, stupid, boring or crazy.

A cognitive model of social phobia

Social Situation=> activate assumptions (I must be funny to be liked)=>NATs (I’m so boring)=> Processing of self as a social object (I look stupid)=> Safety behaviours (force jokes) & =>Somatic and cognitive symptoms

SPC’s have a strong desire to make a favourable impression but have a strong fear of the ability to do so.  SPC’s see a social situation as dangerous, and that it will lead to catastrophic consequences in terms of loss of status and humiliation.

This appraisal of the feared situation then provokes an anxiety reaction, which is then responded to with safety behaviours, processing the self as a social object and NAT’s. The vicious cycle then evolves as the reaction to the anxiety decrease the social performance, through having less cognitive facilities and being less aware of the other and then increases the anxiety.  SP’s generate an image of themselves that they think others see, but this is generated out of their introspective data, i.e. because I feel boring therefore I must look boring.

Safety behaviours then both make the anxiety worse and don’t challenge either the rules that the client has for acceptable social performance or indeed the feared catastrophe should they break these rules.

Two mechanisms contribute to the creation of the self as a social object, pre and post event processing

Anticipatory and post-event processing

SPC’s ruminate about upcoming events. They may plan and rehearse conversations and behaviours. It is at this point that the distorted self-image as asocial object is activated.  Post mortem processing doesn’t add any new data indeed because the Social Phobic was self-focussed rather than other focussed, it also means they ruminate on how bad they felt, and derivatively how bad they must have looked and it stands to be confirmatory of how bad their performance was.

Processing of the self as a social object

The processing of the self is from an observer perspective and is constructed from introceptive data. The distorted sense of self as a social object is the primary target for treatment.

Assumptions and beliefs

The fears of the Social Phobic can be realised, they can be stared at humiliated or rejected. Whilst these events happen to the non-pathological the problem with the SPCs is the meaning they attach to them. 

Whilst SP’s misjudge how they look to others then they also misjudge others, they think everyone else is looking at them and judging them.  Often NATs come out as a self-commentary, my hands will shake, so it is important to find out what the consequences are of this, which will be a belief about others, i.e. my hands will shake and people will think I look stupid.

There are three types of information at schema level

1.       Core self-beliefs, e.g. I’m boring

2.       Conditional assumptions, if people think I’m nervous then they will think I’m incompetent

3.       Rigid rules for social performance: I must always sound fluent and confident.

Social Phobia can often stay dormant whilst rigid rules are maintained and only surface when the rule is badly broken.

The image of the self as a social object can be constructed visually, I look boring, or aurally I sound weak and pathetic, dependent on where the self-consciousness is will depend how the safety behaviour manifests so if you think you sound weak, then you might mentally rehearse what you are going to say.

Symptoms of self-consciousness are also used as evidence that the self-image and the NATs are correct. The construction of the self as a social object also leads to attention being directed to the self and away from other people.

Safety behaviours maintain the problem and contribute to

·         Heightened self-focus

·         Prevention of disconfirmation

·         Feared symptoms, e.g. mental blanks and sweating

·         Drawing attention to self

·         Contamination of the social situation, i.e. make the phobic appear unfriendly

Pre and post mortems maintains the preoccupation with feelings and distorted self-image, it also primes the negative self-processing prior to social encounters.

From cognitive model to case conceptualisation

Eliciting information for conceptualisation

Either use a recent situation or construct one in session with the aid of your colleagues.

Negative automatic thoughts

Thoughts occurring prior to the situation and in situation generally show the same themes. To get these ask about the thoughts when the feelings of anxiety, or somatic symptoms first occur. You need to get the meaning and implications of thoughts, what if I sweat, how much do you think you might sweat, what does this mean, well others will think that I am stupid, so here there are two aspects how much they think they will sweat and what others will think of that.

Anxiety symptoms

Anxiety symptoms are maintained by negative appraisals and are often the focus of negative appraisals.  Anxiety symptoms are either cognitive or somatic and the ones that are most troubling are the ones that are observable to others, such as quivery voice or saying something stupid.

It is important to construct an idiographic formulation of symptoms, so ask, what symptoms bother you most, how conspicuous do you think these symptoms are and if people notice your symptoms then what would that mean.

Eliciting contents of self-processing

1.       Explore the contents of the heightened self-focus, so what does a person think they look like

2.       Question the appraisal of conspicuousness of the self

3.       Determine if safety behaviours link to any aspect of the construction of self

So to do this ask:

·         When you were self-conscious what symptoms where you most conscious of

·         Did you have an impression of how you seemed to others

·         How did you think you appeared

·         If I could have seen you at the time what would I see

Safety behaviours are a channel to provide feared self-image as they are an attempt to manage it so a person who looks down is trying to hide their face as they think it looks stiff or abnormal.

Two questions to probe safety behaviours.

When you try to conceal your symptoms how do you think that you look?

If you didn’t engage in safety behaviours how do you think you would look?

Ask about imagery

The self being seen from the observer perspective usually exists as an image, thus getting the client to describe this can get a detailed description of

Identifying safety behaviour

There is overt and covert safety behaviour, so over would be avoiding eye contact.  Covert safety behaviour is rehearsing what to say before saying it.

To identify safety behaviour then ask is there anything you do to stop your feared outcome, looking boring, or stupid etc. Do you do anything else to improve your performance or manage your symptoms?

What is the effect of your safety behaviour?

·         Your self-consciousness

·         Your performance

·         How friendly you appear

·         Your symptoms

If you create an in-session exposure then you need to be very clear about the active ingredients that create anxiety, so ask for details about the situations in which it occurs what they have in common and times when the phobic situation isn’t a problem.

Socialisation

You can use guided discovery to find out where the evidence is for the rules and assumptions and for the self-image.

Selling self-processing

Do a guided discovery to why they think others are looking at them, and what they see, where’s the evidence kind of springs to mind.

Behavioural experiments in socialisation

These should demonstrate the effects of safety behaviours on physical symptoms, on social performance and on self-processing.

So the experiment is to in a social situation then to use all of the safety behaviours and see what happens, then to drop them and see what happens.  Patients should also be asked to do another experiment where they monitor themselves and then don’t i.e. pay attention to others, again they need to monitor this in terms of consequences in physical symptoms, social performance and self-processing.

Sequencing of treatment interventions

So the sequence would be increase safety behaviours and then remove and see the difference, taking the focus of attention of the self at the same time, then to shift the content of the negative self-image.

The model for Social Phobia is complex and should be presented in stages.  For exposure to happen then the client needs to shift their processing of the self and drop safety behaviours. Manipulations are needed to reduce negative anticipatory processing which can get in the way of exposure tasks.

Modifying self-processing

Exposing to the true self-image is accomplished via audio and video feedback.  To do exposure here then you need to get the client to specifically say what they will look like before, objectively so, as otherwise they may  activate their self-consciousness and skew the results, saying yep there it is that’s what I thought I was going to look like . You need to contrast the self-generated image and the video image. You can also get the client to exaggerate their fears to get them to see what they look like.  Patients can then use rational self-statements, sparingly so I may feel shaky but the symptoms feel worse than they look

Verbal reattribution

Negative self-appraisals and the negative thoughts concerning the reaction of others should be targeted.

Verbal reattribution consists of

1.       Disputing its validity

In some cases there is good reason for their beliefs, so people are rejecting. In that instance then consider strategies for changing the situation.

The general strategy is

1.       Where’s the evidence

2.       Where’s the counter evidence

3.       What’s so bad about it if it was true

4.       If one person thinks something does  it make it true

5.       Do a continuum

The social balance sheet

To disconfirm NATs you can use a social balance sheet, which consists of internal evidence, external evidence and counter evidence. This can show that initially that internal evidence is more used to justify beliefs more than external evidence, in time the external evidence should come more to the fore.

Thinking errors

The predominant thinking errors in Social Phobia are mind reading, fortune telling, personalisation and catastrophising. Social phobics also engage in projected self-appraisal where they think others hold their views of themselves.

Using rational self-statements

Once a balanced view via DTR’s has been made then this can be used as a means of preventing full activation of self-focussed processing, however this should not be used as another safety behaviour, so they should be used once, and not repeated.  They can be effectively used to prevent anticipatory anxiety.

Defining fears

Fears are often ill defined, so if they are made precise then you are in a better place to challenge these fears

Dealing with anticipatory processing and the post-mortem

Anticipatory processing fuels in situation self-processing, i.e. both self-image and self-focus. It can also be safety behaviour where verbal and physical behaviour is rehearsed.  The advantages and disadvantages of this should be discussed. Was it useful, was it accurate?

Again with post-mortem processing because the situation was processed from the basis of self-perception it adds little to an understanding of the situation , again advantages and disadvantages should be looked at.

The final position should be to see that anticipatory processing and post mortems are not useful and should be banned, although this is only the case when the processing is from the self, if you are thinking about what other people said, and to understand them as others then this can be useful

Behavioural Experiments

Doing cognitive restructuring alone is weak as social situations are generally ambiguous so hard to disconfirm beliefs, what you need is a targeted behavioural experiment on one of the beliefs.

Interrogating the environment

So if the client thinks that people are thinking certain things about him, then establish what behaviour would be a reasonable test of this.  Once you get this established then you get the client to act in a way that should provoke this, and you can see if there belief is correct. They may be unwilling to do this, so you can model this behaviour yourself in a social situation. What this aims to do is to decatastrophise the feared event and expose the client to it.

Overcoming avoidance

To counter avoidance then expose to the situation without the safety behaviour which

Working with conditional assumptions and beliefs

Conditional assumptions

Assumptions need firstly clear definition and then to be operationalized in a testable format. Firstly then evidence and counter evidence should be reviewed and then a behavioural experiment performed. You can also get the client to ask probe questions of their audience, I notice I didn’t say very much during that conversation, how was it for you.

Generating alternative evidence

So a social phobic might think having certain symptoms might mean people think that he’s weak, but then you can do a responsibility pie chart to show there are a number of things people might think. Likewise if the client is afraid people are looking at him because he is anxious, then do Socratic questioning about some acting strangely.

Assumption If I get my words wrong people will think I’m inadequate. List all the things an inadequate person lacks, and see how many your client has

Rigid rules

Social phobics generally have rigid rules about social interaction

1.       I must fit in

2.       I mustn’t draw attention to myself

These rules can be challenged with the aim of increasing the bandwidth of acceptable behaviour for a client.  So you can set up a behavioural experiment to challenge them and see the outcome.

Unconditional negative self-beliefs

For instance I’m stupid, so you can challenge this by positive data logs, continua

Positive data log

Once the negative belief has been challenged then you can set up positive data logs, where you can list all the times that the rational response is justified.

Interpersonal strategies

Sometimes people can over compensate, so thinking they are dull, they can attempt to be very interesting and have a deleterious effect on social interactions.

Summary

So social phobia is the desire to be approved of by people and the fear that you haven’t the performance ability to do this.

It is conceptualised as:

Situation= Social

Rules= I must be interesting to be accepted

NAT=I’ve got nothing to say

Self-Image=Seeing self as boring Person

Emotional Outcome=anxiety

Safety Behaviours=ask a lot of questions

The key to working with this, is firstly to psychoeducate, then to show that the safety behaviours are fuelling the anxiety, then to cognitively restructure the rules and NATS through experiment, and do bandwidth expanding experiments for the behaviour

Chapter 8 Generalised Anxiety Disorder

Much of it about 3% in sample population and lifetime prevalence 5%. A person to have GAD needs worrying more days that not, over a range of subjects and find the worry difficult to control and should report at least 3 of the following symptoms:

1.       Restless, keyed up or on edge

2.       Tension

3.       Difficulty of concentrating

4.       Irritability

5.       Sleep disturbances

6.       Muscle tension

The anxiety and worrying should cause significant impairment to functioning

The nature of worry

The content of worry for Gad clients is the same as normal worry, however GAD clients find it less controllable. Worrying is defined as a chain of thoughts and images, negatively affect laden and relatively uncontrollable

The nature of worry in GAD

There can both be the worrying activity and also the feeling of being worried.  Initiation of a worry chain may be voluntary or involuntary, but it is important to distinguish this aspect from the maintenance aspect.  The maintenance of worrying is under conscious control whereas the initiation is less so.

A Cognitive model of GAD

Type 1=standard content of worry

Type 2=worrying about worry

GAD clients have positive beliefs about worrying even though in this model they have type 2 worries.  The GAD client may also feel compelled to reason out the worry to find a solution or to prevent catastrophe. They may believe that you need to worry in order to keep a level of subjective safety, however excessive worrying may decrease vigilance.

Positive beliefs about worrying

1.       Worrying helps me be prepared

2.       Worrying helps me solve problems

3.       Worrying prevents bad things happening

Negative impact of worrying

1.       Makes you more sensitive to threat related information

2.       Generates more worries

3.       Doesn’t challenge the underlying belief of I can’t cope

Worrying may start as problem solving then become pure worry.

Once type 2 worries set in then this produces more problems:

1.       Behavioural responses

2.       Thought control attempts

3.       Emotional symptoms

So what happens?

Trigger=> Positive beliefs about worry=>Type 1 worry=> negative beliefs activated=> Type 2 worry=>(behaviour, thought control and emotions)

Behavioural responses

Two types:

1.       Avoidance

2.       Reassurance seeking

Avoidance can be linked with type 1 or type 2 worries. So to avoid type 1 worries, then you would avoid any triggers that could get you to Type 1. To avoid type 2 then you would avoid putting yourself in situations that you could worry. So if your worrying on choking on nuts then you might chop your nuts up small so you don’t have to worry about it, if you come home after your partner so you don’t have to sit worrying about her then that’s type 2 avoidance as you’re not preventing the object of worry coming true but rather you are preventing worry.

Reassurance seeking also aims to interrupt the worry cycle. Reassurance doesn’t work as it reminds you there is something to worry about, you can get ambiguous advice therefore meaning you can seek more reassurance and it only temporarily allays worry and needs to be repeated.

Thought control

As GAD clients have both positive and negative views about worrying, then worry may be practiced in strict limits that are intended to maximize the benefits and reduce the costs. However thought control, or worry control suffers from the enhancement and rebound effect. Again worry itself may be cognitive or emotional avoidance. Some patients use distraction to avoid worrying, however this prevents disconfirmation of the negative beliefs about worrying.

Emotion

Type 1 leads to increase in anxiety and tension, or decrements if the goals of worrying are being met. However with the anxiety around type 2 then these escalate and prove that type 2 concerns are true. If these get too much then a panic attack may ensure, linking panic attacks and GAD.

Eliciting information for conceptualisation

Verbal strategies for eliciting type 2 worries

1.       Guided questioning

2.       CBA

3.       Identifying control behaviours

4.       Experimental strategies

Guided Questioning

·         What is it that bothers you most about worrying

·         Do you think anything bad will happen if you worry

·         What would it mean if you can’t control your worries

·         What’s the worst that can happen if you don’t control your worries

·         Could anything bad happen if you stopped worrying

CBA

This will give the positive and negative beliefs about worry and the negative should give the type 2 worries.

Identifying control behaviours

Are there any thought control behaviours to stop worrying, e.g. reassurance seeking, rationalising. What would happen if you didn’t do these?

Experimental strategies

Clients may be unwilling to talk about their fears about GAD so elicit it in the room to see what happens and how they respond to it.

Questionnaire assessment

·         GADS (Generalized anxiety disorder scale)

·         TCQ (Thought control questionnaire)

·         PSWQ (Penn State Worry Questionnaire)

·         WDQ (Worry Domains questionnaire)

From Cognitive Model to Case Conceptualisation

So the type 1 worry creates emotions, physiological responses, then type 2 creates these and thought control and behaviours.

Socialisation

Ask if you were to stop worrying about x would that solve your problem. Client would usually say no there would be something else to worry about. Therefore you can argue would it be better to deal with what keeps the worrying going rather than an individual worry. Once this idea is in place you can suggest part of the problem that keeps worrying going is what you think of worrying.  Everyone worries, why is it a problem for you, should lead to some negative appraisals of worrying, some type 2 stuff.

Worrying Thought Record

This has a column for worry about worry and can help the type 2 worry awareness.

Socialising experiment

Suppression experiment

So do a white bear experiment. This should lead to a banning on control behaviours.

What if experiment

Some patients report worrying as an attempt to solve problems and increase coping strategies. The aim of this experiment is to show how a worrying style of thinking exaggerates problems.  So start with something bad happening and follow it with what if something else bad happened and take it on to utter disaster. Ask how useful this is with reducing stress and helping you cope, ask about what emotions were produced.

Selling worry as a motivated strategy

At a later stage in treatment you need to show the patient that their use of worry to solve problems is supported by their positive beliefs about worry. Do this by a CBA.

Modifying Meta-Worry and negative beliefs

Here the aim is to challenge type 2 beliefs.

Verbal Reattribution

Questioning the evidence

What makes you think worrying can make you go crazy. Operationalize crazy, find out the evidence that worry can take you there.  You could also try a behavioural experiment to make yourself crazy by worrying.

Questioning the mechanism

Question the causal mechanism that sees worry leading to catastrophe, so for instance, worry creates stress, stress causes people to have mental breakdowns, so therefore all soldiers have mental breakdowns. Humans have evolved from highly stressful situations how could this have been the case if stress makes you go mad. Individuals suffer stress but don’t go mad.

Challenging uncontrollability appraisals

Worry is complex and demanding mental activity and is generally displaced by competing mental activities. As soon as you see this then you can see the controllability of worry. So are you worrying when you are just about to go to sleep, do you worry when you are having a conversation with a friend. So ask when they worry and when did eventually stopped, then show that something took their mind off it, so worry must be controllable.  Look though at the problems of trying to control worry.

Education (normalising worry)

Worry is a normal phenomenon, most people worry on a weekly basis.  In a study at least 79% of people worry over a two week period.

Dissonance techniques

Positive and negative beliefs about worry provides some dissonance that can be used for motivation. So expose and highlight the two contradictory beliefs that the client holds.  Then ask which one would the client go for within the contradiction.

Imagery techniques

Images can be a worry trigger, in this case they can be finished out, or rescripted, but care needs to be taken that this doesn’t become a source of reassurance or safety behaviour.

Behavioural Experiments

Controlled worry periods

Borkovec thought that worry is learned as a coping response to an initial fear reaction and represents a cognitive reaction to avoid future trauma.  However Borkovec saw worry as uncontrollable. So what Borkovec is arguing for is that worrying has got stimulus control, in that if we see fear, or to prevent future trauma we worry. So what the worry period is to do, is to increase discrimination ability and restore the power of when to worry and when not to.

Stimulus control technique as advocated by Borkovec is

1.       Identify worrisome thought

2.       Establishment of a 30 minute worry period to take place at the same time and location each day

3.       Catching oneself worrying and postponing the worry to the worry period and replacing the worry with attending to the present moment

4.       Use the 30 minute worry period to worry about ones concerns and to engage in problem solving to eliminate those concerns

Wells criticises this as it introduces worry control which may support type 2 beliefs and that he believes worry can be useful.  For Wells the worry control period is used to challenge beliefs about the uncontrollability of worry.

Wells worry control period

Set up.

Worrying is a complex and demanding thought process. Whilst it may seem uncontrollable this is to the case, as you can see when you stop worrying for instance when driving and something happens, or a phone call from a dear friend.

1.       Set up a 15 minute time during the day when you can worry

2.       When you first notice that you are worrying postpone your worry by telling yourself that you can worry in your worry period.

3.       When that time arrives if you feel like worrying then worry about the things you have previously thought about

You should rate the belief in the uncontrollability of worry before and after.

Loss of control experiments

You can also use a worry period to challenge the belief I could lose control, so get the client to worry as hard as they can and see if they can lose control.

Pushing worry limits in situ

Get clients in vivo to exaggerate their worries and to record the reaction of others and on the situation again to challenge their beliefs that they will go mad, lose control etc.

Abandoning thought control

Get a behavioural experiment where the client worries without their safety behaviours to show they are unnecessary. Once this has been succeeded then thought control should be banned

Surveys

The possible negative responses of others towards worry can be challenged through surveys.

Modifying positive beliefs about worry

Standard verbal reattribution techniques can be used

1.       Questioning the evidence

2.       CBA

Mismatch strategies

Implicit in the assumption that worries prepare you for the future is that worries provide an accurate view of the world.  Therefore you should explore the content of worries and what actually happens, although you would need to go back in time a bit to find the worry that relates to the therapy period.

Retrospective mismatch

Think back to a time, e.g. before an important social event when worry occurred, identify what the content of worry was and what actually happened.  The power of this is to describe in as much detail as possible. When this is pulled out, then get the description of the actual event. Of course this can be prone to self-fulfilling prophecies, but chance worth taking.

Prospective mismatch

You can get the client to enter worried about situations, with a clear understanding, through homework of what was going to happen, then a comparison with what actually did. This can also reverse avoidance.

Worry abandonment experiments

Worrying more can also challenge the positive beliefs about worrying. So have a problem and worry a lot more about it than usual and see if the problem is fixed, or that mental performance is increased. Compare this against a non-worry period.

Modifying Cognitive bias

Individuals are hypervigilant for type 1 and 2 worries.  So if the individual repeatedly searches for data consistent with his worries, get them to search for information inconsistent with their worries. If the client repeatedly searches for worrisome information then when finds it worries, ask them why they don’t just do it once.

However searching for inconsistent evidence shouldn’t be used as a way of averting the danger of the type 1 worry, it may still happen, what you need to understand is that the probability of it will diminish.

You can also do experiments to see how hypervigilance affects the sense of vulnerability, does doing it a lot make you feel more vulnerable or less.

Strategy shifts

New endings for old worries

Owing to long standing use of worry, i.e. negative cognitive rehearsal, clients have limited experience of other ways of responding to mildly uncertain or negative events.  The aim here is to look for more positive outcomes from the mildly uncertain events, the aim here is to make the thinking process more flexible so good and bad events can be considered.

Letting go of worries

Acknowledge the presence of the worry and let it go, you could even say to yourself, here’s a worry it doesn’t mean anything so let it go, or you can think of the leaves on a stream, or trains in  a station.  This is best used later on in therapy so it doesn’t become a thought control technique

Avoidance

Avoidance could be about type 1 or type 2 worries so you need to know which to be able to do exposure on them

The problem of co-morbidity

Worry is a characteristic of most emotional disorders.  If depression is comorbid then it should be treated first as it will interfere with treatment.

Chapter 9 OCD

OCD is ego dystonic where the client thinks there obsessions and compulsions are unreasonable.  Obsessions and compulsions are part of normal human behaviour what distinguish the diagnosis from normality is the distress\disruption levels.

Cognitive models of OCD

Perfectionism=McFall, inflated responsibility=Salkovskis, cognitive deficits in decision making Reed, thought action fusion Rachman, meta cognitive beliefs Wells.

The Salkovskis model

Salkovskis brings together previous thinking around inflated responsibility, belief about thought and action with behavioural principles and the primary determinant of OCD being the misinterpretation of the intrusion.  So having an intrusive thought is like performing the action, so not neutralising the thought is akin to doing the action.  Negative appraisals of the intrusion are amplified in depressed states due to the accessibility of the negative schemas.

Inflated responsibility is key in Salkovskis, but Purdon argues this is an over-emphasiation and it is the metacognitive beliefs on the need to control thoughts that should be given special consideration. Wells argues that cognitive beliefs concerning the danger and power of intrusive thoughts and the attentional strategies used by obsessionals are significant in OCD.

Wells meta-cognitive model

Intrusions activate beliefs about the significance of the intrusion. Rachman introduced TAF. Having TAF beliefs will result in thought control behaviours, and actions to attempt to invalidate the thought\action.  Thus a person has a thought and therefore thinks they have done it, or it will happen. Under standard conditions they would refute this but under triggering conditions it seems more believable.  People with TAF blur internality with externality. 

Whilst some behaviours are designed to neutralise the thought others are intended to relieve worry.  Neutralising behaviours are designed to reduce stress but may well become a source of distress themselves as they are seen to be time consuming, irrational and uncontrollable.

IN summary Wells believes that the central aspect of OCD are the beliefs connecting thought and action and positive and negative beliefs about worry and neutralising. In short a meta-cognitive position, no surprise there then.

OCD clients have an intrusion, then dwell on it to dispute its validity, which increases its significance to the point that it has to be neutralised with compulsion. The compulsion breaks the worry chain through distraction and is associated either with the initial intrusion or meta beliefs about it.

Attentional strategies

Attentional strategies are seen to maintain OCD.  The attentional strategies are those of monitoring for certain thoughts. They argue that internal events are given priorities to external events, so even if something is done, the imagined consequences of not performing it are fantasised about. To make more important fantasies and doubts, reduce the reliance on memory, and confidence in action.

A general working model

Trigger=> activates meta beliefs=> Appraisal of intrusion<=>Beliefs about rituals

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Behavioural response and emotional response

There are two types of behavioural response, positive and negative. Positive to prevent the content of the intrusion happening or to prevent the bad feeling that comes from the intrusion. The negative is my compulsions are out of control I have to stop them.

Maintenance

Emotional

 The feedback loops that happen are the anxiety produced by the trigger, the appraisal and the behaviour then goes to feed the negative interpretation that something bad is really happening. So anxiety can support the idea that I’m out of control, or that my appraisal of my intrusion is true.  Again a lowered emotional state can make you more prone to triggers and more sensitive to obsessional intrusions. Again the production of anxiety might support the idea that one is being overwhelmed by the feelings generated by your intrusions and you must perform your compulsions.

Behavioural

They prevent the disconfirmation of the metabelief about the intrusion as they keep the client safe. If the behaviour is thought suppressing then you get maintenance through the rebound and enhancement effect. Checking can set up associations between a variety of things and the original intrusion. Compulsions provide a continual preoccupation with obsessions.

Developing a case formulation

In order to develop a case formulation you need to

1.       Establish trigger situations

2.       Establish precise detail of obsession and compulsion

3.       Establish meaning of the obsession and meaning of the compulsion

Symptom profile and triggering influences

It is useful to find out what profile the triggers have so what is the pattern during the day.  You can also find it hard to elicit the intrusive thoughts as the client is only aware about their compulsions. You can do this through self-monitoring and behavioural tests.

Eliciting dysfunctional appraisals

Appraisals of intrusions

·         When you had your intrusion how did you feel

·         When  you felt x what went through your mind

·         Did you have any negative thoughts about the intrusion

·         What does it mean to you to have these intrusions

·         Could anything bad happen to you as a result of these intrusions

·         What would happen if you couldn’t get rid of these intrusions

Appraisals of behavioural responses

Check the appraisals and beliefs in the behavioural responses

·         What would happen if you didn’t do  your compulsions

If you get compulsions without obsessions it suggests that the compulsions are not aimed at reducing danger around a specific thought but it doesn’t mean there is no appraisal. It could mean that the compulsion is aimed at reducing emotions or that there are emotional consequences of not doing the compulsion. So there could be a feeling of distress and the appraisal that if they don’t do their compulsion then this distress will be unmanageable. There can be feelings generated around doing the compulsion which can again form into a feedback loop. I do my compulsions to manage negative feelings but my compulsions create negative feelings.

·         Do you do anything to prevent the catastrophe happening from your intrusion

·         Negative outcomes

o   Could anything bad happen from following your compulsions

o   What’s the worst that could happen from following your compulsions

·         How much control do you have over your compulsions

·         Positive outcomes

o   Do your compulsions keep you safe in some way

·         Have you tried to stop, in which case why

·         What happens to your thoughts and feelings when you are prevented from following your compulsions

So just to recap you need to understand the obsession and what the appraisal is. The obsession might be a thought or an emotion. Then you need to understand the compulsion and what the positive and negative aspects about it are. You need to understand what the trigger situations are and you need to find out the pattern of when the OCD relationships happen.

Socialisation

To socialise share the conceptualisation! You can do the white bear to show thought suppression doesn’t work.  You can also look to see if the client thought the intrusions were normal and not harmful then would there be a problem, them saying yes opens up the meta cognitive space.

General aims of cognitive therapy

The aim in this framework is to reduce the negative appraisal of intrusions.  There can also be a worry component around OCD and a negative belief in its uncontrollability in which case you should use worry windows, to show that worry is controllable.  The overall aim is to get the client to generate a detached acceptance of either an intrusion or a worry as not anything that needs to have anything done about.

Verbal reattribution

Defining the cognitive target and detached mindfulness

So the client is encouraged neither to worry nor to neutralise their obsessional thought. This can be either done with a worry window or a letting go of the thought. A reduction in symptoms using this approach can be used to show it is the appraisals about the intrusions rather than the intrusions themselves that are the problem.

Clients can be unwilling to stop their worry or neutralising tied up with negative thoughts of what may happen.  These negative beliefs should be surfaced and challenged.

Once the role of negative appraisal is accepted, you should normalise intrusive thoughts in that 90% of people have them.

DTR in OCD

Separating worries about intrusions from intrusions helps clients discriminate their types of thought. The dtr in ocd has Situation, trigger, Intrusion, emotion, worry about intrusion, answer to worry and rerate emotion. DTRs don’t change beliefs overnight so should be repeated.

Thought action defusion

So reattribution:

1.       How does thinking cause action

2.       Is the person who is concerned about what they think, going to be concerned about how they act

3.       Have you been unable to neutralise a thought, did you act?

So TAF can be worked on by

1.       Questioning the mechanism

2.       Incongruence that if you care about thoughts you are likely to care even more about action

3.       Historical review, where compulsions haven’t been performed did the feared action take place

Thought event defusion

Thought event fusion is where you think it and it will happen\is true. So I think I have knocked someone over.. Thought action fusion is where you think it and you will do it, I have a thought about harming kids therefore I will do it. With TEF there’s the belief my thought is true, then the compulsion happens to reduce the worry.

To socialise to TEF you need to look at the tacit belief of how catastrophic it would be or how responsible they would feel if the thought were true. You can then weaken the type 1 worry as the level of awfulness if it were true is seeming to make its truth stronger, do you have thoughts that you don’t believe, what’s the difference.

So the therapist should work at the meta-cognitive level, challenging why they think this thought is valid and get the client to give up their counter-productive invalidation strategy.

·         What prompts you to your compulsion

·         If you didn’t believe your obsession would you do your compulsion

·         How does checking affect your confidence in your memory

·         How does your checking affect your ability to distinguish between imagined and real events

Rational responses can be this is just a thought, just a fantasy and not reality and I don’t need to reason with it, detached mindfulness. Indeed you could in session do ERP and get them to think the thought and not to respond to it, just to think about it as a thought.

Identify Images

An image can be a trigger, in which case examine the evidence of where the evidence is that makes the image real. If feelings predominate then use this to explain the concept of emotional reasoning.

Behavioural reattribution

ERP: the behavioural perspective

This is that the compulsions reduce the fear\anxiety of the obsessions and are thus negatively reinforced. So they prevent habituation occurring with anxiety. So expose to the fear allow anxiety to reduce of its own accord and become habituated. Steketee showed 40-75% improvement on target symptom measures.  ERP doesn’t work so well on pure obsessions. ERP doesn’t work so well with people with higher depression levels and who show higher belief in their ideas (Foa 1979)

ERP a cognitive reconceptualization

In wells framework compulsions prevent disconfirmation of misinterpretation of the obsession. Compulsions also maintain preoccupation with the obsession indeed some may increase them.  Compulsions may also deplete cognitive resources needed for meta cognitive operations needed for belief changes.

So this ERP exposes to the obsessional thought, to see that nothing bad happens, suspending the compulsion also means reducing its maintaining and enhancing effect.

Challenging specific beliefs

·         Increase frequency/intensity of obsessions to challenge feared outcome

·         Test specific fears, so if a client fears they will stab someone but doesn’t want to then get them to be closer to knives

·         If a person thinks that thinking certain thoughts will make them come true, then get them to have bad thoughts about  you and see if they come true, ensure though you know what their safety behaviours are

Response prevention: contamination fears

Use a magic solution that has some of the toxic element in but is invisible so can’t be washed off.

Absence of cognition

Some clients report a general feeling of distress associated with not performing their compulsion. The first step is to determine the nature of the distress. There may be fears of the distress not receding or an inability to cope and these should be explored. There may be images or impulses that are the trigger obsession.

In the case of distressing urges or images, ritual prevention can be sold on the basis of teaching greater emotional tolerance.

As the client tries to eliminate it without success you can try to enhance it, to see what they can tolerate. So if they have an image get them to turn the brightness up on it. You can also do a paradoxical twist on intrusions seeing them as an opportunity to practice acceptance and something to be welcomed, this will reduce the type 2 problems.

Additional considerations

Rituals and emotional avoidance

Some clients have very time consuming rituals and you should look for them to have other ways to structure their day. Some clients don’t have any obsessions to speak of, in which case you should find out what would happen if they didn’t do their compulsions.

Doubt reduction

The occurrence of constant checking has been linked with memory deficits, however the evidence is inconclusive, rather it is more likely checkers show reduced confidence in their memory.  There are techniques to enhance memory, such as making an image of that which you did, or to use coloured shapes to indicate certainty and to remember the coloured shape when they do their action, but these seem to miss the point that checking increases doubts about memory.