Phobic anxiety. :Paul Salkovskis p.salkovskis@iop.kcl.ac.uk Institute of Psychiatry Centre for Anxiety Disorders and Trauma, Maudsley Hospital Phobic anxiety.


Prevalence of anxiety disorders in representative samples of the general population :Prevalence of anxiety disorders in representative samples of the general population (Prevalence of anxiety disorders in children: 4%)


The present status of CBT for anxiety :The present status of CBT for anxiety CBT is the treatment approach with the strongest current evidence base CBT is strongly grounded in empirical research CBT is offered to only a minority of patients likely to benefit from it Most people who have been (and are being) trained to deliver psychological treatments are not trained to offer CBT


Slide 4:People experiencing mood fluctuations (mild anxiety, worry) Acute anxiety or depression of greater severity More severe & persistent mood problems with disturbance of social/occupational functioning Persistent and severe mood disorder Chronic and disabling mood disturbance Multiple chronic disabling problems and disorders Clinician expertise required Delivering psychological treatment: funnel model (after Goldberg)


Self help: what you need to know to make a difference :Self help: what you need to know to make a difference Knowing that you have a problem Knowing what the problem is Knowing how the problem works Knowing what to do Knowing how to do it Knowing who to turn to for support Knowing when you need more


Self help :Self help Understanding emotion Understanding anxiety Understanding anxiety “disorder”


You hear a noise in the middle of the night … :You hear a noise in the middle of the night … Stupid cat annoyed Partner pleased Burglar scared It’s the meaning that matters!


Cognitive model of emotional response: the simplest version :Cognitive model of emotional response: the simplest version Event Meaning of event Emotional response


Which emotion when? Emotions are specific to particular meanings :Which emotion when? Emotions are specific to particular meanings Depression: Personal loss Anxiety: Threat or danger to you Anger: Someone broke your personal rules (unfairness) Guilt: You broke your own rules


Anxiety and threat :perceived likelihood it will happen Anxiety is proportional to the perception of danger; that is Anxiety and threat X + perceived “awfulness” if it did perceived rescue factors perceived coping ability when it does ___________________________


Behaviours motivated by belief :Behaviours motivated by belief In emotional problems, behavioural responses are motivated by the meaning and implications of a particular situation Behavioural change can maintain and/or worsen negative appraisals, and therefore maintain emotional disturbance


Safety seeking behaviours :Safety seeking behaviours Behaviours intended to prevent harm Several effects on beliefs prevent disconfirmation can increase the stimuli which are misinterpreted increase preoccupation and rumination Are linked to the specific focus of threat by the internal logic of the person employing them


Slide 13:negative interpretations Events and situations Reactions to perceived threat Cognitive model of the persistence of anxiety


Slide 14:negative interpretations Events and situations Automatic reactions Cognitive model of the persistence of anxiety Strategic reactions


Ideas of danger in phobia :Ideas of danger in phobia This thing will harm me My response to this thing will harm me


The biggest obstacle to self help for those who know…. :The biggest obstacle to self help for those who know…. Panic attacks


Slide 17:sensation The panic vicious circle


Assessment :Assessment Identify recent episode Set the scene (prime memory) What was the first sign of trouble? Questions used to identify the sequence Frequent use of summaries Was this typical? If not, then follow up with a different attack Draw out sequence Check with the patient Homework: do own vicious circle from tape


Meaning links bodily sensations and misinterpretations in panic :Meaning links bodily sensations and misinterpretations in panic Heart racing, pounding. I'm having a heart attack, my heart will stop palpitations Breathlessness. I'm going to stop breathing, suffocate. Feeling unreal and distant. I'm going to go crazy, lose my mind. Loss of sensation and I'm having a stroke. tingling in arms and legs. Feeling dizzy, faint, weak legs. I'm going to faint, fall over, pass out. Feeling distant, tense and I'm about to lose control of my behaviour. confused Feeling dizzy, heart pounding, I'm dying. chest tight and painful, palpitations.


Slide 20:sensations interpretations emotions sensations interpretations Deriving a vicious circle from an endless sequence….


Slide 21:sensation The panic vicious circle


Slide 22:“What was the first sign of trouble?” Sensations “What did you notice in your body?” Interpretations “When those sensations were happening, what was going through your mind at that moment?” “What seemed to you, at that moment, to be the worst thing which could happen?” Emotions “How did that idea affect the way you felt emotionally?” AS CIRCLE DEFINED: “WHAT DID THAT DO TO……” Deriving a vicious circle: key questions


Slide 23:short of breath “I’m going to pass out” frightened and petrified The panic vicious circle: spiralling out of control thinking about going where you previously had a panic attack


Slide 24:short of breath “I’m going to pass out” frightened and petrified The panic vicious circle: spiralling out of control thinking about going where you previously had a panic attack “I’m dying”


Self help: what you need to know to make a difference :Self help: what you need to know to make a difference Knowing that you have a problem Knowing what the problem is Knowing how the problem works Knowing what to do Knowing how to do it Knowing who to turn to for support Knowing when you need more


How psychological treatments work :How psychological treatments work People suffer from anxiety because they think situations as more dangerous than they really are. Treatment helps the person to consider alternative, less threatening explanations of their problem If the alternative explanation is to be helpful It has to fit with your past experience It has to work when you test it out Good therapy is about two people working together to find out how the world really works Good self help is about one person setting out to find out how the world really works


Ideas of danger in phobia :Ideas of danger in phobia This thing will harm me My response to this thing will harm me Self help must lead you to the conclusion: This thing won’t harm me My response to this thing won’t harm me


Overview of the cognitive theory of emotion (1) :Overview of the cognitive theory of emotion (1) The same event can have different meanings for different people (or even for the same person on different occasions) It is this meaning which gives the event its emotional impact Emotional problems arise because of problems in the way in which the person organises and interprets reality.


Overview of the cognitive theory of emotion (2) :Overview of the cognitive theory of emotion (2) These problems in turn tend to occur because of learned attitudes or assumptions which the person previously used to make sense of their world. Treatment involves some combination of (i) the correction of counter-productive beliefs and interpretations (ii) learning and testing alternative ways of interpreting their experience (iii)helping the person to make changes in their situation (iv) Helping patients to try different ways of behaving consistent with the alternative account of their problems


CBT: Treatment style is structured :CBT: Treatment style is structured External structure: Defined no. of sessions Regular review of progress inc. weekly questionnaires Internal structure: collaboratively set: Agenda Goals Review homework / progress Change methods New homework


“The Good Therapy Guide” :“The Good Therapy Guide” Preference for choice of treatment: “Doctor knows best” Shared decision making Evidence based patient choice Preference for therapist


Questions to ask about your therapist :Questions to ask about your therapist What qualifications / experience do you have? Don’t be impressed by titles Ask about specific experience with your problem & current caseload Ask about their supervision Trainees: not necessarily a problem Less likely to be dogmatic More likely to be “up to date” More likely to be enthusiastic More likely to have supervision


Getting the most out of your therapy: preparation :Getting the most out of your therapy: preparation Prepare a brief time line and history of your problem Be aware of things which you find difficult to discuss. Try to decide not to keep important secrets (once comfortable with your therapist). Anxiety likes secrets. Writing things down can help, either as notes for yourself or to hand to therapist Ask for reading Make sure you are on time & don’t miss sessions


Preparation cont.: Think about your goals :Preparation cont.: Think about your goals Short term goals: goals which you can reasonably be achieved in 2-4 sessions Medium term goals: what can reasonably be achieved by the end of therapy Long terms goals: what you would like to do over the next few years, particularly emphasising positive changes and “growth” targets Specific, Measurable, Achievable, Realistic, Testable Things to enjoy or look forward to, not just things to not do.


Unhelpful beliefs :Unhelpful beliefs This is my last chance to get better. This problem can only be managed: I’m kidding myself if I think I can overcome it. A setback = failure = back to square one. My problem is unique. Having these this problem makes me a bad person/is my punishment. Avoiding things is the only way out of this problem. I should keep secrets in therapy or not discuss some thoughts or my therapist will be shocked. A problem that’s been around for this long will take even longer to treat. We have to discover the cause if we are going to treat the problem


Some helpful ideas :Some helpful ideas Not every journey that starts with a single step has to take 1000 miles Aim to be as consistent as possible in doing this, rather than doing it as a quick test that you force yourself to do It’s not just what you do, it’s how you do it that’s important: cheating just delays progress Your unlikely to get this right all the time & that’s ok – people never progress in a perfectly straight line Setbacks are helpful provided you pick yourself up and keep going The Golden Rule with safety seeking behaviours in anxiety: always do the opposite of what the problem tells you to do


How does exposure reduce anxiety? :How does exposure reduce anxiety?


Cognitive account of the effects of exposure :Cognitive account of the effects of exposure Prolonged exposure allows the person to achieve disconfirmation, that is, they discover that the things they fear do not happen. This is not an explicit target, and happens “incidentally” in BT. Less likely when “within situation” safety seeking behaviours are present.


Safety behaviours studies :Safety behaviours studies Brief, tightly controlled study to address the theoretical issue Somewhat longer clinical study in order to establish the clinical effectiveness of therapy incorporating safety behaviour focussed procedures.


Agoraphobia treatment experiment :Agoraphobia treatment experiment Standard behavioural walk 1 Self report questionnaires 5 minute behaviour test 1 15 minute experiment 5 minute behaviour test 2 Brief treatment: 1 hour planning + 2 x 1.5 hours in vivo Standard behavioural walk 2 Self report questionnaires 2 days 7-10 days


Agoraphobia experiment design :Agoraphobia experiment design Standardised behaviour test Standardised behaviour test 15 mins exposure with a habituation rationale 15 mins exposure with a cognitive rationale Standardised behaviour test


Slide 42:Cognitive condition Non-cognitive condtion


Slide 43:Cognitive condition Non-cognitive condtion


Agoraphobia treatment study :Agoraphobia treatment study Participants from previous experiment continue in protocol 1 hour of treatment planning 2 x 1.5 hour sessions of in vivo exposure All treatment sessions completed in 10 days maximum All subjects asked not to change lifestyle for this period


Slide 45:Agoraphobia treatment experiment


Agoraphobia experiment participants :Agoraphobia experiment participants No differences in age, sex, severity, clinical measures Equivalent credibility for each intervention n=18 panic disorder with severe agoraphobia


Agoraphobic cognitions :Agoraphobic cognitions ***


Panic frequency :Panic frequency ***


Agoraphobic avoidance :Agoraphobic avoidance ***


Steps achieved in behavioural walk :Steps achieved in behavioural walk ***


Peak anxiety during behavioural walk :Peak anxiety during behavioural walk ***


Beck Anxiety Inventory :Beck Anxiety Inventory ***