11

Managing Anxiety

A One Day Online

Skills-based CBT Workshop

www.rcpsych.ac.uk

Paul Blenkiron

2

CBT in Practice 2021

• Three one-day practical workshops + course materials

• You can attend all of them or just one or two

• Suitable for psychiatrists, nurses, psychologists, GPs

• No prior experience is assumed. Focus on adults

• Online via Zoom, 9.30 to 4.15pm

Introduction to

CBT

Managing

Depression

Managing

Anxiety

Thurs 18 March Thurs 15 April Mon 17 May

3

CBT in Practice 2021

• A range of three skills-based courses online -designed to help you implement Cognitive Behaviour Therapy within your practice and service.

• Led by trainer: Dr Paul Blenkiron, Consultant Psychiatrist, TEWV NHS, York, paul.blenkiron@nhs.net Twitter @PaulMindDoctor

• Organised by The Royal College of Psychiatrists

Centre for Advanced Learning & Conferences https://www.rcpsych.ac.uk/events/conferences

• Emma.George@rcpsych.ac.uk Tel: 0208 618 4143

We’re on Zoom Today – Ground Rules

4

5

About this Workshop

• Teaching techniques:

– Interactive presentation, DVD clips, practical exercises,

group work, analogy, quiz, self evaluation and feedback

• Facilitator:

– Paul Blenkiron: consultant psychiatrist

– Honorary Professor, Hull York Medical School

– CBT Tutor for Core Psychiatry Training, North Yorkshire

– BABCP-accredited CBT Therapist (British Association for Behavioural and

Cognitive Psychotherapies)

– Public Engagement Officer, RCPsych

6

‘

7

Learning Objectives

After this workshop, participants will be able to:

1) Understand the principles of CBT for anxiety

2) Help patients to understand and modify thoughts

and behaviours that maintain anxiety

3) Begin to treat phobias using graded exposure &

‘SMART’ targets

4) Begin to treat panic disorder using Clarke’s

Cognitive Model

8

9

Plan for the Day

• 9.30: Introduction & CBT Overview

• 9.45 : What is Anxiety? Group work

• 11.00: BREAK

• 11.20: CBT for Generalised Anxiety. Mindfulness

• 12.00: Graded Exposure for Phobias

• 1.00: Lunch

• 1.30: CBT for Panic: DVD clips & role play

• 3.00: BREAK

• 3.15 Safety Behaviours, CBT summary, Quiz

Resources & Feedback

• 4.00 Close

10

Let’s Start

• Have you ever experienced extreme

anxiety? How did you get through it?

• Do you have any phobias? (that you are

willing to admit to!)

• One question I would like answering today

is…….. (Type in Chat)

Video 1:

STOP IT!

Managing Anxiety: How not to do CBT

By Bob Newhart https://www.youtube.com/watch?v=Ow0lr63y4Mw

12

Revision: Workshop 1

In ‘Introduction to CBT’ we covered:

• What is CBT? ‘CHANGE VIEW’

• Suitability

• Evidence base (NICE guidelines)

• Assessment: 5 areas

• Style: Guided discovery (Socratic Q: 4 parts)

• College training requirements

13

What is CBT?

CBT is a psychological treatment that teaches us how to feel better by changing the way we feel think and behave……

• Here and now

• Problem/disorder focus

• Collaborative/self help style

• Structured/measured

• Homework

• Evidence based (NICE)

CBT- It’s How You View It

14

CBT: Socratic QuestioningA person is more likely to integrate and accept that which is reached by his own reasoning process” (Miller 1983).

What it is

• An inquisitive questioning style

• Helps them find their own

answers to their problems

• 4 parts: Ask, Listen,

Summarise, Synthesise

• Non-confrontational but skilful

• Non-leading - but has purpose

• Encourages more helpful ways

of thinking & reacting

What it is not

• A therapy ‘prescription’

• Seeking to persuade with

logic or evidence

• Warning of negative

consequences

• Setting a plan without

negotiation

• Arguing, disagreeing,

challenging, interpreting,

criticising or blaming

15

4. Plan

5. Intervention

6. Evaluate

7. Summarise

Review and revise formulation

as more information emerges

Assessment

Formulation

Engagement

1.

2.

3.

these 3

‘stages’

overlap

Steps in CBT

Staying well plan

17

Who is Suitable for CBT?

More suitable

From history/referral letter……

• Specific & focused problem

• Single problem or diagnosis (Axis I-mental ‘illness’ eg panic, depression)

• No drug or alcohol misuse/psychosis

• Acute problem of recent onset

• First contact with psychiatric services

And when seen face to face….

• Good therapeutic alliance

• Can be focused in sessions

• Can identify emotions & thoughts

• Can relate to CBT model (‘five areas’)

• Can agree goals (written down)

• Takes personal responsibility for change

• Optimistic

Less suitable

• General & pervasive problem

• Multiple/complex/severe problems (Axis II – personality disorders)

• Substance use/active psychosis

• Chronic long-term problem

• History of treatment failure

• Problems in therapeutic relationship

• Vague & circumstantial in sessions

• Unable to access thoughts/ emotions

• Can’t link thoughts, feelings & actions

• Cannot specify desired changes

• Does not accept self-help model

• Hopeless

How Effective is CBT?

0

10

20

30

40

50

60

70

80

90

100

% complete

therapy and

achieve

sustained

excellent

outcome

Pan

ic/P

ho

bia

s

GA

D

So

cial

Ph

ob

ia

OC

D

PT

SD

Dep

ress

ion

(Adapted from Salkovskis, 2002)

19

Revision: Workshop 2

In ‘CBT for depression’ we covered:

• What is depression? (mnemonic)

• Maintenance formulation (role play - 5 areas)

• Behaviour therapy for depression: activity

scheduling, diary keeping, goal setting

• Cognitive therapy for depression: challenging

‘ANTs’, thought diaries, behavioural expts

Situation/ event/ stress

Thoughts (images, memories, etc)

Emotions

Behaviour Physical

reactions

CBT:Putting the pieces

together

The ‘generic’ CBT

formulation

organises

assessment

information

It shows what

caused the problem

and what keeps it

going ……

(Generic means ‘fits all’. There are

also specific CBT formulations for

different problems)

Our ‘core beliefs’ & assumptions (‘rules for living’)

(Early) Life events

Causal fa

cto

rsM

ain

tain

ing f

acto

rs

2121

1st and 2nd Generation• *Behaviour therapy (Operant and

Classical Conditioning)

• *Graded Exposure, Flooding, Systematic Desensitisation, Implosion

• *Classical Cognitive Therapy (Beck)

• *Problem Solving Therapy (Nezu)

• *Specific models eg Exposure & Response Prevention (ERP) for OCD, Cognitive Therapy for Panic, Trauma Focussed CBT for PTSD

• *CBT (and PSI) for Psychosis/Bipolar

• Schema-Focussed Therapy

• Rational Emotive Therapy (Ellis)

• *Cognitive Analytic Therapy (CAT)

3rd Generation CBT• *Behavioural Activation for Depression

• Compassionate Mind Therapy (Gilbert)

• Metacognitive therapy for *GAD (Wells)

• Mindfulness (eg for *RDD, OCD. GAD)

• *Dialectical Behaviour Therapy for BPD

• Acceptance & Commitment Therapy (ACT)

• Schema Mode Therapy (Young)

• Writing therapy (Pennebaker)

• Analogy Therapy (Blenkiron)

Plus Delivery: *Face-to-face (Individual, couple, group) or Self Help (Guided /*Unguided) via *book, *computer, phone, apps, email…..

The CBT Family

* = In NICE Guidelines

CBT for AnxietyListen to your patient: they are trying to tell you the diagnosis (William Osler)

)

22

23

Video 2:

Anxiety (2 mins)

• Observe how Dr Buckman (GP) explains

anxiety to his patient (John Cleese) ….

• What would you do differently?

24

What is Anxiety?

• Balloon Experiment

25

What is Anxiety?

Group Work – 15 mins

• What is anxiety? What is its purpose?

• List the main symptoms (physical and mental)

• What is ‘stress’? Is it the same as anxiety?

• List the main anxiety disorders (ICD-10/DSM-5) –which ones do you see most in your job?

• Give an example or analogy that could you use to explain anxiety to patients?

What is Anxiety?

Notes:

1. What is anxiety? What is its purpose?

2. List the main symptoms (physical and mental)

3. What is ‘stress’? Is it the same as anxiety?

4. List the main anxiety disorders (ICD/DSM) – which ones have you seen as a psychiatrist?

5. What examples or analogies could you use to explain anxiety to patients?

27

•

Fight or

Flight?

Performance v. Arousal

• What happens to our performance as

physiological arousal increases?

= Yerkes-Dodson Curve 1908. We perform best at moderate levels of arousal. Also applies to stress hormones & learning ie

formation of long tem memories is best when cortisol levels are moderately (not very) high

GAD-2 Screening Tool(NICE, 2013)

Over the last 2 weeks, how often have you been

bothered by the following problems?

1) Feeling nervous, anxious or on edge

2) Not being able to stop or control worrying

Scoring: 0= Not at all 1= Several Days 2= More than

half the days 3= Nearly every day. An anxiety disorder

is likely if a person answers 2 or 3 to one or both Qs (ie

anxiety present > 50% time) http://ebmj.com/content/12/5/149.full

•

•

29

30

Assessing Anxiety: The Worry Tree

Pyramid of Diagnosis

31

a) ORGANIC:

acute (delirium)

chronic (dementia)

b) SCHIZOPHRENIA &

PARANOID PSYCHOSES

c) AFFECTIVE PSYCHOSES:

mania / bipolar / psychotic depression

d) NEUROSES: depression/OCD/PTSD

phobias, panic & generalised anxiety disorder

e) A D J U S T M E N T D I S O R D E R S

f) P E R S O N A L I T Y D I S O R D E R S

Hierarchical model of psychiatric diagnosis. Basic principle is that where more than one psychiatric diagnosis, those disorders further up take precedence. Modern categorical classification

systems eg ICD-10 & DSM5 still based on this 19th century Kraeplinian concept. Any physical (organic) illness can present as any mental illness below it (so rule out physical causes first eg

brain tumour can cause psychotic symptoms, stroke can cause depression and alcohol withdrawal can cause panic attacks). Working from bottom up, those with PDs can have an

adjustment disorder (eg distress leading to an overdose after split from partner) or any other condition above it. Those with severe depression plus anxiety Sx may be labelled ‘agitated

depression’. Diagnose an ‘adjustment disorder only if Sx milder/short lived ie do not fulfil criteria for a diagnosis above it. If someone has Sx of depression (4 or more for over 2 weeks) then diagnose clinical depression even if caused by a life event , not adjustment. For anxiety ask: is it part of any other mental disorder above it (secondary) on the hierarchy?

Anxiety: Treatments

• Education / explanation

• Relaxation

• Advice on sleep and exercise

• Cognitive behaviour therapy = a psychological

treatment that teaches us how to feel better by changing the way we feel think and behave = change behaviour (eg graded exposure) and/ or change thinking (eg anxiety is unpleasant but not dangerous)

• Medication:– Antidepressants eg sertraline (an SSRI) or venlafaxine (an SNRI)

– Benzodiazepines eg diazepam (max 2-4wks)

– Beta-blockers eg propranolol

– Pregabalin

– Antipsychotic drugs eg haloperidol

33

NICE Guidelines for Anxiety 2011

34

What Maintains Anxiety?

• Group discussion:

What sort of ……

a) thoughts and

b) behaviours….

keep anxiety going?

• CBT = encouraging patients to understand

and drop these ways of reacting

35

What Maintains Anxiety?

5 AreasSituation

External triggers (phobias)

Internal: thoughts/body sensations (panic)

Thoughts

Catastrophic misinterpretation,

Danger/ threat/coping

Controlling/suppressing thoughts

Worry about worry Body

Symptoms

Physical & mental:

‘fight or flight’,

derealisation

Behaviours

Avoidance/escape, safety

seeking, reassurance, checking,

selective attention,

hypervigilance

Emotions

Anxiety, fear,

panic (lack of

knowledge &

understanding)

36

CBT for Stress

37

Healthy Coping:

Stress Bucket

Model: Example:

CBT for Work StressCochrane Review Ruotsalainen 2021 (9 RCTS n=706)

• CBT reduces occupational stress symptoms

& prevents burnout in health care workers (13% relative risk reduction at 1 to 6 months, not before)

• Adding relaxation or meditation to CBT

gives no added benefit

• Also effective: Physical relaxation eg massage, and changing work

schedules (eg giving weekend breaks)

• Not effective: Mental relaxation alone eg meditation, and other employer

interventions eg giving support or changing work conditions

38

Assessing Anxiety:

Useful Questions

Feelings: use their words: scared, etc

Physical: body: hot, jelly legs, tingling

feeling unreal/distant etc

Thoughts (+ beliefs, images,

memories)

• Listen for themes of

threat/danger/vulnerability

• What's the feared ‘catastrophe’?

• What are their beliefs / (mis)

interpretations?

• Are they overestimating the

chances/costs of this happening?

• Are they underestimating their ability

to cope?

Behaviours

• What do they do to cope?

• Examples of ‘escape’ or avoidance behaviours?

• Examples of selective attention to body sensations?

• Other ‘safety behaviours’?

• Which are helpful and unhelpful coping strategies?

• Thinking ahead to sharing the formulation, can you draw an arrow from behaviours to thoughts or situation to identify vicious circles?

• “Does avoiding the supermarket reduce your thoughts that you will have a heart attack there? Increase them?”

39

Video 3:

Paul’s Social Anxiety

40

What is

maintaining

his anxiety?

Can you

think of a

behavioural

‘experiment’

to test out

his

assumptions

?

Using the

‘5 Areas’ CBT

formulation:

to explore links

between thoughts,

feelings & actions Play from 4.26-9.38mins

Building the CBT Formulation:

Paul’s Social Anxiety

41

Why am I the way I am ( Beck’s Longitudinal Model) What keeps the problem going ( 5 Areas Hot Cross Bun)

42

Break

43

44

CBT for Generalised Anxiety

Behavioural: ‘Anxiety management’:

eg Jacobson’s Progressive Muscle Relaxation, Controlled Breathing, Distraction, Exercise

Cognitive: Tackle ‘worry about worry’:

• Test out unhelpful beliefs about worry eg ‘worry helps me solve problems’ v. ‘worry will make me go crazy/kill me’

• Mindfulness: awareness plus acceptance

• Stop trying to suppress/control worry eg think of any animal you like for 30 secs, except it must NOT be a pink elephant……..

45

46

Why Worry?

Some Quotations

• As a rule, men worry more about what they can't see than about what they can. Julius Caesar, 100-44 B.C.

• Worrying is like a rocking chair; it gives you something to do, but it doesn't get you anywhere.

• Worry is interest paid on trouble before it is due. WR Inge,1860-1954.

• Today is the tomorrow we worried about yesterday

47

Managing Anxiety:

Square Breathing

Mindfulness

• Mindfulness is ‘Purposeful and non-judgemental attentiveness to one’s own experience, thoughts and feelings’

• Notice your thoughts: view them as objective events that happen to us: this enables us to gain a new perspective on how negative thoughts affect our emotions and behaviour, allowing us to manage the distress that would normally accompany them

• Focus on the present moment, not on your distressing thoughts Let it be: ‘Get out of your head and into your life’

• An example: Notice you are reading this slide. Then notice you are noticing yourself. How do you do this?

• Note: ‘3rd Generation’ CBT focuses on changing our relationship with our thoughts, not the content. Examples: behavioural activation, (BA), mindfulness + acceptance & commitment therapy (ACT) Useful for: depression (BA = don’t sit there thinking about how useless you are, do something), GAD (don’t worry about worry) & OCD (don’t argue with/resist/try to stop upsetting thoughts)

49

Mindfulness Exercise:

Floating Leaves• This exercise will help you see the difference between looking at your

thoughts and looking from your thoughts. Imagine you are on the bank of a steadily flowing stream, looking down at the water. Upstream, some trees are dropping leaves, which are floating past you. Just watch them passing by, without interrupting the flow. Whenever you are aware of a thought, let the words be written on one of the leaves as it floats by. Allow the leaf to carry the thoughts away. If you have a picture thought, let a leaf take on that image. If you get thoughts about this exercise, see these carried along on a leaf too.

• At some point, the flow will seem to stop. You are no longer on the bank seeing the thoughts on leaves. When you notice this, see if you can catch what was happening just before the flow stopped. There will be a thought you have ‘bought’. See how it took over. Notice the difference between thoughts passing by and thoughts thinking for you. Do this whenever you notice the flow has stopped. Then return to the bank. Once again, let every thought find its leaf as it floats past (Mace, 2007)

50

•

Exercise…

Mindfulness of the

Breath (10mins)

Be in touch - moment by moment - with the breath as it enters the body

Sit with the qualities of a mountain. Let each breath come & go of its own accord

Stay with the breath at a particular place in the body such as the belly or nostrils

Ride on the waves of each breath sensation, with your full awareness as best you can

Eventually, the mind will take off – this is totally normal and not a problem at all It’s in the nature

of the mind to wander – it waves as the ocean waves. And if the mind wanders a thousand

times, as it surely will, just bring it back to this breath, without being harsh or critical. It’s never

a matter of putting a stop to this

Each moment is the only moment, no matter what our thoughts are telling us

Reference: The Mindful Way Through Depression: Freeing Yourself from Chronic

Unhappiness. Mark Williams, John Teesdale, Zindel Segal & Jon Kabat-Zinn. Guildford, 2007.

Book with CD: Guided Meditation (70mins). Track 4 Mindfulness of the breath (10 mins)

51

Graded Exposure for

Phobias

52

What Maintains a Phobia

53

Explaining Exposure to Patients

54

Graded Exposure

• The deliberate confrontation of a feared object

or situation until anxiety reduces considerably

• Needs to be…

– Clearly specified & planned (‘S.M.A.R.T’ targets)Specific… Measurable…. Achievable…. Relevant…Time limited

– Prolonged

– Repeated frequently (‘homework’)

– Graded (eg ladder or steps)

– Without dissociation

55

Types of Exposure Therapy

• Self-directed, or accompanied by therapist, friend or relative

• In reality or imagination (eg PTSD/trauma)

• Gradual or one-off prolonged (‘flooding’)

• Systematic desensitisation ( = graded exposure plus relaxation

?unnecessary)

• Done in CBT session, then as homework

56

Indications for

Graded Exposure (NICE)

• Specific phobias & agoraphobia (= treatment of choice)

• OCD (exposure and response prevention = ERP)

• PTSD (trauma-focussed = imaginal and in reality)

• Panic disorder = exposure to internal body sensations to

discover they are not dangerous

• Social phobia = drop safety behaviours, test out fears

• Health anxiety (hypochondriasis) = ditto

57

Example 1: Anxiety Ladder for

Rachel’s Bird Phobia

1. Put picture of robin on bedroom wall

2. Watch Hitchcock film ‘The Birds’

3. Visit pet shop: stand next to caged parrots

4. Walk in park past duck pond

5. Walk in park, sit on bench and feed ducks

58

Example 2: Graded Hierarchy for

Joan’s Agoraphobia

1. Enter my local corner shop with exact money +

buy a newspaper

2. Purchase more than one article

3. As 2, but wait for change

4. As 3, waiting behind one person

5. As 4, but waiting in a queue at busier time etc

(NB if begin to panic, I will stay inside the shop till

my anxiety falls to under ‘half max’ before leaving)

ERP for OCD

60

Example 3: John’s OCD

Checking List

1.……… the cooker (least feared)

2.………… the kettle

3.…………… the gas fire

4.……………… the windows

5.………………… the doors (most feared)

John could not leave the house on time for work every day, because he had to check so many things. He worried that the house might burn down, or he might be burgled if he did not check certain things 5 times each. He made a list of what he was checking, starting with the easiest to tackle (see above). He began with step 1. Instead of making sure that the cooker was switched off several times, he checked it only once (exposure). At 1st he felt very anxious. He stopped himself from going back to check again. He agreed not to ask his wife to check everything for him as well, and not to ask her for reassurance that the house was safe (response prevention). His fear gradually lessened over 2 weeks. Then he moved on to step 2 (the kettle) and so on. Eventually, he could leave the house without any checking rituals and get to work on time.

•

61

Video 4 (12 mins)

Graded Exposure for

Agoraphobia

Easy in theory –

But needs skill to apply in practice!

62

Quotes for

Overcoming Anxiety

• ‘She feared she’d die if she tried…

But when she tried, her fears they died’ (Anon)

• ‘Feel the fear and do it anyway’ (Susan Jeffers)

• ‘Try to do the thing you cannot do’ (E Roosevelt)

• ‘Just do it’ (Nike)

• Do more of the same if it’s working, do something

different if it’s not... ‘If you always do what you

always did, you’ll always get what you always got’

63

Group Discussion

• Why is graded exposure - simple in

theory - often challenging to practice?

• Troubleshoot potential problems in

helping a patient overcome a phobia

• Notes:

64

65

Graded Exposure:

Tips for Success

• Anxiety ladder is the patient’s, not yours

• Patient agrees and records their targets 1st

• Goals are clear – ‘no gain without pain’

• Patient keeps exposure diary (anxiety

before, during, after) and notes successes

• Practice …. until targets become ‘boring’

66

CBT for Agoraphobia:

Formulation Exercise• Linda is a 45 year old single woman whose life has become

increasingly restricted over the past 7 years. The only place she feels completely safe is in her own home. She avoids going to supermarkets like Tescos. However, she can make it to the local corner shop on a “good” day if her friend Brenda comes with her. She always carries diazepam or a packet of mints just in case and tries to do things quickly so she can get home. She never uses public transport, but can drive short local routes as long as traffic is not too busy.

• In queues, crowds in shops and heavy traffic, she feels sick, “unreal”, hot and notices “butterflies” and a pounding heart. She thinks she will lose control and embarrass herself, and also that she will collapse or something terrible will happen. She always has to get out of the shop immediately, and usually rings her sister on the mobile phone for support.

• In fact these days she rarely experiences bad attacks as she avoids most fearful situations. As a result , she now leads a very restricted life. Linda has not worked for 3 years and shops on the internet. She misses her former social life with her friends, especially trips to the cinema & pub.

• Draw a maintenance formulation … How can CBT help?

Formulation Diagram:

68

69

Linda’s Motivation Matrix

70

Facing Your Fears:

A Motivating Story

Once upon a time, there was a lion who strayed from the jungle where he lived, and found himself lost in a desert. He walked on and on in this arid land, becoming thirstier and thirstier. Finally he saw a pool of water. ’At last!’ he thought, ‘I can quench my thirst’.

He ran towards the pool, but as he lowered his head to drink there was another lion already in the pool! The lion quickly retreated. When he tried to approach the pool again, once more the fearsome lion stared up at him. Backwards and forwards he went, getting more and more thirsty, but the other lion always barred his way to the water.

Finally he was so thirsty that he marched right up to the water’s edge, thinking ‘I don’t care about that other lion, or how fierce he is. I must have water to survive!’ He plunged his head into the water and began to drink…..

…… And as he did so, the other lion disappeared in shards and splinters of reflections in the pool. (Shah, 1983)

71

Lunchtime

72

Panic Disorder

73

Panic Disorder: Definition

Panic attacks = surges of unpredictable, intense fear (peak within 10mins, last 20-45mins)

Panic disorder = repeated panic attacks that include at least 4 of the following:

• Physical symptoms: racing heart, sweating, shaking, breathlessness,

dizziness, numbness, tingling, chills, hot flushes, choking, chest pain, nausea, ‘butterflies’

• Mental symptoms: derealisation (feeling that world is unreal as in a dream) or

depersonalisation (feeling detached from oneself, like an actor on a stage)

• Fears of losing control, going crazy, dying, having another panic attack or physical

effects (eg heart attack, stroke, suffocating)

(DSM-IV-R)

74

CBT for Panic: Summary

• Education: anxiety is normal, fight or flight

• Draw a vicious circle (diagram with arrows)

• Exposure to own body sensations

• Experiments: test out fears to disprove them

– Dizziness = ‘I will pass out’: hyperventilation

– Racing heart = ‘I’ll have a heart attack: jogging

75

Video 5: Panic

• Mary describes her panic attack to her

therapist (Christine Padesky, ch 2): 8

mins

Introduction to wk1:

mood disorders

SensationHeart racing,

sweaty

InterpretationI’m having a heart attack

EmotionFear, panic

Panic : A Vicious Circle

Fill in the Blanks (1)

Palpitations

Chest pain

Fear ? I’m having a

heart attack.

I’m dying.

Fill in the Blanks (2)

?

Fear I’m going to

faint and

collapse

Overbreathe, feel dizzy & unreal.

79

Panic PairsMatch each symptom to the appropriate fear

Symptom

• Dizzy

• Breathless

• Palpitations

• Tingling fingers

• Feel unreal

• Headache

Catastrophic Meaning

• Heart attack, dying

• Brain tumour

• Stroke

• Going mad

• Faint, collapse

• Suffocate

Fill in the Blanks (3)

Shortness of

breath

Fear I’m going

to

suffocate ?

Run

outside

Hold onto

something

Fill in the Blanks (4)

Churning stomach

Nausea

Fear

Suck mints

Drink water

Deep breaths

?I’m going to vomit.

I’ll make a fool of

myself.

82

Video 6: Panic Model

• Observe how the therapist explains

Mary’s panic using Clarke’s vicious

cycle model (ch3, 6 mins)

83

84

Clarke’s CBT Model

for Panic Attacks (1986)

• The trigger can be external (eg crowds) or internal (eg heartbeat) – ‘selective attention’/ ‘hypervigilence’

• The person misinterprets normal body sensations as meaning that a physical or mental disaster is imminent – ‘catastrophic misinterpretation’

• The ‘fight or flight’ survival response produces more symptoms - which fuel the ‘vicious cycle’ of panic

• Attempts by the person to manage panic bring short term relief but make it worse in the long term (avoidance + safety behaviours)

85

Deriving the Vicious Cycle:

Pair work

15mins each then swap roles ….

Therapist:

• Question the patient about a recent typical example of a panic attack, then feed this information back using the cognitive model of panic.

• Use the 5 areas approach or Clarke Model (see other handout). You can use the questions below as a guide.

• Summarise frequently. Repeat what they say. Use their words.

• Use a pen and paper to draw out a ‘vicious cycle’ diagram when you feed back to the patient.

Patient:

• Choose a patient you know whose problem is panic disorder - or use a vignette provided (‘Jo(e)’ or ‘Nick’y). Feel free to make up the details.

• Only give information to the therapist if s/he asks for it specifically. On the other hand, please don’t be deliberately awkward.

• When the therapist feeds back, say if something is unclear or inaccurate.

Deriving the Vicious Cycle

Notes:

87

Taking a Panic History :

Useful Questions

• When did you last experience a panic? How typical was it?

• What was the very first thing you noticed when it started?

• What body (physical & mental) sensations did you notice?

• When the sensations were at their worst……

• What went through your mind at that time?

• What sort of pictures or images did you have?

• How did you feel?

• What was the worst thing that you feared might happen?

• What did you do to save yourself? What did you fear might have happened had you not been able to do that?

• What do you avoid doing now?

88

Example 1: Nick(y)

• Your main problem is panic attacks. These occur every day now. They are very intense, lasting between 15 & 45 minutes. They can happen anywhere, but more often in crowded places like shops and pubs.

• During a typical panic you feel things are not real and feel detached from what is going on around you. You get a humming in your ears, blurred vision, shaking, and lots of worrying thoughts. You fear that you will lose control & go crazy. You have a vivid picture of being locked up in an asylum (as in “One Flew Over The Cuckoo’s Nest”).

• You attempt to control these panics by keeping busy and talking to others. You always carry diazepam tablets (but rarely take them)

• The problem started 2 years ago when you were under a lot of stress at work. You had your first panic in bed, so now you avoid going to bed until you are really tired. You drink lots of coffee to stay alert. You can’t relax as you are constantly looking out for the next panic attack.

89

Example 2: Jo(e)

• Your main problem is panic attacks 4 or 5 times a week. They last about 20 minutes and involve intense fear. You notice yourself sweating, with a racing heart, chest tightness and tingling fingers.

• When you panic, you fear that you are having a heart attack and will die. You believe this 95% (but only 15% when not panicking)

• During a panic you take your pulse, thump your chest hard a couple of times to reassure yourself that your heart is still working and sit down.

• Your first panic was "the morning after the night before", following a party when you got drunk. You do not avoid any situations as the panics occur anywhere, anytime.

• You avoid exercise because it increases your heart rate and might bring on a heart attack. You have also stopped drinking all alcohol. You have noticed distraction helps, so you try to keep yourself busy

90

Steps in CBT for Panic

• Individual formulation and education about panic

cycle (‘socialisation to the model’)

• Generate alternative non-catastrophic explanations

• Test these out: behavioural experiments (recreate

symptoms/ drop safety behaviours)

• The eventual aim of therapy is for the individual to

be able to experience the symptoms of panic

without feeling frightened

Behavioural Experiments

• Reproduce body symptoms that bring on

panic (= Symptom Induction = Internal exposure)

• Q What are the most common panic

symptoms? How might you bring them on?

92

Behavioural Experiments:

Examples

• Hyperventilation provocation test: patient and therapist stand & overbreathe together till dizzy to prove fainting/collapse does not occur (BP + pulse rise in panic, but falls in vasovagal syncope) See notes pages view for details

• Chest pain exercises: (to prove not cardiac or fatal): fill lungs with air then shallow breaths reproduces chest tightness. Or breathe in + press finger between ribs to show skeletal not cardiac

• Spinning round in a chair: dizziness

• Exercise: jogging on spot

• Focus on Body Sensations: eg warmth and tingling in limbs (to show normal but may induce panic). Or place book on patient’s outstretched hand for 2 min: demonstrates pain does not mean body abnormal

93

Behavioural Experiments:

Examples (cont)

• Try to Panic! Therapist asks patient to deliberately have a panic attack in session there & then (They can’t ie not out of control).“I can go mad/kill myself just by thinking about it” Therapist and patient think for 2 minutes like this together: nothing happens

• Stare at a dot on the wall (derealisation/fear of going mad)

• Paired associates experiment : to prove link between thoughts and physical sensations. Patient reads out a list of paired words and asked to “dwell on them as if they apply to you” + note effect eg breathless –suffocate, chest tight – heart attack, palpitations – dying,dizziness – fainting, numbness – stroke, unreal – going mad

• Surveys: Fear of going blind due to “floaters” or tension headaches meaning brain tumour: ask ten people if they have had same experiences…. do they all have a brain tumour?

Behavioural Experiment:

OCD

94

95

Video 7:

Hyperventilation

• Induction experiment: Mary agrees to over-

breathe for 1 min to create panic symptoms

• How does the therapist help Mary to test out

her fear that she will collapse with a heart

attack? (ch4, first 6 mins)

96

Behavioural Experiments

• Design ‘no lose’ experiments:

– Theory A versus theory B (a racing heart means I will have a heart attack v. a racing heart in panic is harmless)

• P.E.T.S. approach: – Prepare: rate catastrophic belief eg if my heart races I will have

collapse with a heart attack & die (95% belief)

– Expose (to body sensation): eg jog on spot for 5 mins in hot room (1st

check PMH ie fit and well, not pregnant)

– Test: drop safety behaviours eg don’t sit down, don’t hold on, don’t check pulse, stand on 1 leg, ‘try’ to have an MI

– Summarise: what have you learned ,re rate belief

• ‘Don’t trust me, test me’! (A.T. Beck)

97

Break

98

Safety Behaviours

• A safety-seeking behaviour is an unnecessary

action intended to stop a feared catastrophe

from happening (Telch, 2012)

• Although this reduces short term distress, it paradoxically

makes the fear stronger – by preventing the person from

discovering the disaster was not going to happen

(Salkovskis, 1999)

• Overcoming anxiety = having the confidence to tolerate

anxiety whilst dropping these behaviours.

• Exposure + not doing SBs = better outcome (Meyer, 2019)

Safety Behaviours:

Examples

• Barbara has a thunderstorm phobia She fears being struck by

lightening so she only goes outside on ‘safe’ weather days – when the sky looks blue and completely

free of clouds with no rain forecast. As she lives in England, this means that she has been virtually

housebound for over twenty years. To this day, Barbara continues to believe that she is only alive

because of her weather-watching actions.

• Tom has social anxiety He avoids speaking in work meetings and to

strangers at parties. He fears people will notice him blushing. So as not to draw attention to himself,

he puts his hand in front of his face when talking and avoids eye contact. However, this makes

people stare at him to try and understand what he is saying. He holds his drinking glass really tightly

to control shaking, but this makes the shaking worse. He also wears a vest under his shirt to hide

underarm sweating which only causes him to perspire more.

• Simone has panic attacks & agoraphobia She shops ‘on-

line’ and only visits the supermarket at night when it is quiet. She carries medication for anxiety

(diazepam) in her pocket, although she has never used it. If she feels a panic attack coming on, she

holds onto the shopping trolley to prevent herself collapsing and ‘losing control’ then runs out the

nearest exit. 99

100

Drop Safety Behaviours

Addressing beliefs about safety behaviours….

The Vampires and Garlic Story…..

101

Safety Behaviour:

Pair Exercise (5 mins)

• People with social phobia often try to

appear confident by planning ahead …..

• Engage in polite conversation with your partner about your favourite hobby

• 2 rules to follow:

• Must plan each sentence before speaking

• Must look in control and not smile

• Feedback (‘post-mortem’): how did it go?

102

Thought Records in Anxiety

• Identification of key catastrophic thought(s) that is

causing/maintaining the anxiety

• Examination of evidence to support this thought

• Gathering evidence that doesn’t support the thought

• Constructing an alternative, more realistic belief

SMART adaptations of thought records for anxiety:

1. Test out predictions: thought records are not sufficient alone

to treat panic: don’t talk, do!

2. Well’s Metacognitive Model: look at reactions to the thoughts

(‘thoughts about the thoughts’)

103

104

Panic Diary: Example

• Situation: at home doing washing up. Panic intensity = 80%

• Worst symptoms: chest pain, palpitations, dizziness.

• Worst fears: I’m having a heart attack (90%)/ dying (80%)

• Safety behaviours: sit down, take pulse, control breathing

• Alternative explanation: Coffee causes palpitations. The

breathlessness & dizziness came later so it’s anxiety again

• Behavioural experiment (next time it occurs): remain

standing, don’t take pulse, accept it’s panic

• Predictions: ‘The symptoms will get worse and I will have a

heart attack’ versus ‘It will be unpleasant but it will pass’

• Outcome:…. Well I’m still alive aren’t I?!

105

106

Summary: Key Points

• Anxiety is normal. It helps us perform (‘fight or flight’)

• Anxiety disorders include GAD (excessive worry),

panic (extreme bursts) & phobias (specific fears)

• A central goal of CBT = ‘do the thing you cannot do’

(ie stop avoiding, safety seeking, thinking the worst)

• Offer graded exposure: to external cues for phobias,

to internal (body) symptoms for panic

• Any questions?

107

Quiz a) Name that Phobia

1. Claustrophobia

2. Arachnophobia

3. Acrophobia

4. Tocophobia

5. Pantophobia

….. Is a fear of…..?

1 Point each, total max =15 for quiz.

For answers, see ‘normal view’ on PowerPoint

108

Quiz b) NICE Guidelines

True or false? NICE guidelines for anxiety recommend:

1. Self help, SSRIs and therapist-led CBT as equally valid 1st line approaches for panic disorder

2. Beta-blockers for panic if SSRIs are ineffective

3. Patients with specific phobias (eg cats, heights) are offered the choice of an SSRI or graded exposure

4. Avoiding referral to specialist secondary care services in the absence of significant risk

(1 Point each)

109

Quiz c) Safety First

1. Margaret practices ‘square breathing’ whenever she goes into a supermarket and feels herself begin to panic. This calms her down and allows her to continue shopping. Is this a safety behaviour or a helpful coping strategy?

2. You find out that she is also drinking 100 units of alcohol a week. Is graded exposure contra-indicated?

(1 point each answer)

110

d) CBT for Anxiety

True or False?

1. The aim of CBT for panic disorder is to experience symptoms without feeling fear

2. The aim of CBT for generalised anxiety is to remove or control worrying thoughts

3. The aim of CBT for a phobia is to stay in the situation till anxiety falls below 50% of maximum

4. It is better to test out catastrophic fears in reality than challenge them ‘logically’ in a thought diary

(1 point each, total = 15 for CBT quiz)

Quiz: Answers

a) Name that phobia:

1) Enclosed spaces 2) Spiders 3) Heights 4) Childbirth 5) Everything

b) NICE guidelines:

1) T 2) F (use imipramine or clomipramine 2nd line) 3) F (medication is not

indicated for uncomplicated specific phobias) 4) F (step 4 = refer complex or

comorbid cases to CMHTs)

c) Safety behaviours:

1)Helpful coping strategy (provided she is not doing it to avoid some feared

catastrophe)

2)Yes (self medication prevents anxiety rising to a level that proves it is not

dangerous, and won’t remember new learning). Treat alcohol dependence

first

d) CBT for anxiety: 1) T 2) F 3) T 4) T 111

112

First Steps

‘I paint

objects as I

think them,

not as I see

them’

Pablo

Picasso

1881 –

1973

113

What Next?

• CBT on the job (‘don’t just prescribe, do something!’): special interest

• CBT for yourself (manage stress)

• CBT supervision groups (contract, audio-record sessions, self rate

on CTRS, SAPE, ACE)

• Become a member of the BABCP (British Association for

Behavioural and Cognitive Psychotherapies – the lead UK organisation for CBT, open to

all, £27 for trainees) www.babcp.com

• Further CBT training… eg RCPsych CALC, Oxford www.octc.co.uk

114

115

CBT Books

• Introductory CBT Books for Professionals 1. Westbrook, D., Kennerley, H. & Kirk, J. (2007). An Introduction to Cognitive Behaviour Therapy. London: Sage Publications.

2. Blenkiron P. (2010) Stories & Analogies in Cognitive Behaviour Therapy.Wiley-Blackwell http://www.amazon.co.uk/Stories-Analogies-Cognitive-Paul-Blenkiron/dp/047005896X/ref=sr_1_4?ie=UTF8&s=books&qid=1242745779&sr=8-4

• Self Help CBT Books for the Public1. Greenberger, D. & Padesky, C.A. (1995). Mind over Mood. N.York: Guilford

2. Williams, C. (2001). Overcoming Depression: a Five Areas Approach. London: Hodder-Arnold. Also Overcoming Anxiety, Stress & Panic (2009).

• National Books on Prescription Scheme‘Reading Well’ list of 30 approved CBT self help books available via English public libraries www.readingagency.org.uk/readingwell

116

8 Great CBT Websites

• Free Web-based CBT self help programmes: http://www.livinglifetothefull.comhttp://moodgym.anu.edu.au

http://mindfulnessforstudents.co.uk/resources/

• Free patient information on CBT/mental disorders:

http://www.rcpsych.ac.uk/mentalhealthinfo UK College website

http://www.ntw.nhs.uk/pic Northumberland Tyne & Wear self help booklets

http://www.getselfhelp.co.uk/ Great CBT resources from one therapist

http://readingagency.org.uk/adults/quick-guides/reading-well/National Books on Prescription Scheme 30 self help CBT Books endorsed by experts

NHS Digital Apps Library https://apps.beta.nhs.uk/about-us

117

Useful Resources

• Blenkiron P. Who is suitable for cognitive behavioural therapy? Journal of the Royal Society of Medicine 1999; 92: 222-229 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1297171/

• Padesky, C.A. (1993). Socratic Questioning: Changing Minds or Guiding Discovery? Keynote address, European Congress of Behavioural & Cognitive Therapies, London http://www.padesky.com/clinicalcorner/pdf/socquest.pdf

• Blenkiron P. Stories and analogies in CBT: a clinical review. Behavioural and Cognitive Psychotherapy Jan 2005, 33, 45-59. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=264987

• CBT for Schizophrenia. Drug and Therapeutics Bulletin, 48(1), Jan 2010. http://dtb.bmj.com/content/48/1/6.full.pdf

• IAPT Data Handbook (for Rating Scales & Outcome Measures)http://www.iapt.nhs.uk/silo/files/iapt-data-handbook-v2.pdf

My Favourite

CBT Questions

• At Start: What do you want to get out of seeing me/ our conversation today?

• At End Can you summarise what we’ve discussed? What’s the most important thing you’ve learned from our conversation?

• Motivation: Why now? Why change? Costs v benefits/ Pros v cons

• Cognitive Therapy: What’s a more helpful way to look at this? How would you advise a friend?

• Behaviour Therapy: The Miracle/ 3 Wishes question. If all your problems were solved, what would you be doing

differently?

119

Workshop Evaluation

• And self assessment

paul.blenkiron@nhs.net

Thank You

Additional slides:

Anxiety Models

121

CBT: Vicious Cycles

122

CBT Model for a Specific Phobia

Vomiting is unbearably awful and terrible for me

AvoidanceEncountering the phobic object / situation

Catastrophic beliefs

Autonomic arousal

Pre-attentive activation

High

degree

of

convictio

n

Escape or safety behaviour

Prevents

disconfirmation

The catastrophe does not occur and anxiety reactions dissipate

Conclusion drawn: The escape / safety behaviour prevent the catastrophe

The catastrophic belief is confirmed

The phobia remains unchanged© Think CBT Ltd info@thinkcbt.com

01732 808 626 www.thinkcbt.com

Cognitive Model of Social Anxiety Wells and Clark (1997)

Social Situation

Activates assumptions

Perceived social danger(negative automatic thoughts)

Processing of Self as a Social Object

Safety behaviours

a

Somatic & cognitive symptoms

Wells, A., 1997. Cognitive Therapy of Anxiety Disorders: A Practice Manual and Conceptual Guide.Chichester: John Wiley & Sons Ltd.

© Think CBT Ltd info@thinkcbt.com

01732 808 626 www.thinkcbt.com

Cognitive Model of OCD

(Salkovskis)

Intrusive thoughts, images, urges, doubts

Misinterpretation of significance of intrusions –responsibility for actions

Neutralising actions (rituals,

reassurances etc.)

Attention and reasoning biases

(looking for trouble)

Mood Changes (distress, anxiety,

depression)

Counterproductive “safety” strategies (though suppression, impossible criteria,

avoidance etc.)

© Think CBT Ltd info@thinkcbt.com 01732 808 626 www.thinkcbt.com