CBT FOR ANXIETY

MANAGEMENT OF ANXIETY
Medications (e.g. SSRIs)
Two main strands
of treatment: ‘Talking Therapies’ such as
Cognitive Behavioural
Therapy (CBT)

The best effects are seen when medications and CBT are
combined.
WHEN DOES ANXIETY
BECOME A DISORDER?
Anxiety is a normal human response to objects, situations or events that are
threatening

Moderate level of anxiety can be helpful and adaptive (e.g. anxiety about
giving lectures!)

Anxiety becomes a disorder when out of proportion or when it

significantly interferes with life.
Since High levels of anxiety can often paralyse individuals and cause
physical and emotional discomfort (Freeman, 1989).
Cognitive-behavioural therapy (CBT) is one of the most well-
researched and efficacious treatments for anxiety disorders.

CBT differs from other CBT sessions often

therapeutic orientations in that it occur weekly for a
is: limited period (e.g.,
12–16 weeks), and

a small number of
highly structured often manualised booster sessions are
sometimes offered to
reinforce the independent
use of skills.
COGNITIVE BEHAVIOURAL
THERAPY

At its core, CBT refers to:

a family of interventions and techniques that promote
more adaptive thinking and behaviors in an effort to reduce
distressing emotional experiences (2).
WHAT IS THE AIM OF CBT?
To increase self-awareness

To encourage a better self-understanding

To help us recognize the ‘negative traps’ or ‘vicious cycles’ we get

caught in (see fig. 3)

To improve self-control by developing more appropriate cognitive and

behavioural skills
PRINCIPLES OF CBT
A
A person’s
person’senvironment, emotions,
environment, emotions,thoughts (cognitions)
thoughts and behaviours
(cognitions) and are
behaviours are all linkedall(see
linked
fig.(see
2). fig. 2).

Our thoughts, ideas, mental images, beliefs and attitudes can sometimes be
‘errors’ which are unhelpful and lead to
emotional disturbances and physical reactions.

These emotional and physical disturbances result in behavioural patterns which

are intended to
reduce anxiety (safety and escape behaviours) or avoid anxiety-provoking
situations (avoidance behaviours).
 THE NEGATIVE CYCLE

Confirms negative Negative thoughts

thought SITUATION

Feel disinterested, unmotivated

Creates doubts/worries

Affect what you do

Produce unpleasant feelings

Make you feel sad, depressed,

anxious and uptight

Fig. 3 Stallard, P. 2002

COGNITIVE-BEHAVIOURAL
CONCEPTUALISATION OF ANXIETY
DISORDERS INCLUDES IDENTIFICATION OF:
dysfunctional
thinking patterns When each of these three components
interact and mutually reinforce one another,
distressing and impairing levels of anxiety
can be maintained over time.

distressing
unproductive feelings or
behaviours physiological
experiences
Therapists work with clients to recognize how negative thought patterns influence a
person's feelings and behaviors.
Here's an example of how two different people can react to a situation differently
based upon their thoughts:
CBT uses a mixture of cognitive (thought processing) and behavioural
techniques to look at the links between a person’s environment, thoughts,
feelings and behaviours-
and the impact of these on their health and functioning.

address thoughts and thought patterns which may be

Cognitive ‘unhelpful’ and may trigger and/or increase anxiety
techniques

address behaviours which may be used by a person to

Behavioural reduce their anxiety or avoid it altogether
techniques
COGNITIVE INTERVENTIONS
One of the primary CBT strategies is cognitive intervention.

In brief, CBT holds that one’s emotional experience is dictated by one’s

interpretation of the events and circumstances surrounding that experience
(2, 3).
Anxiety disorders are associated with negatively biased cognitive distortions
(e.g., “I think it’s 100% likely I will lose my job, and no one will ever
hire me again”).
The objective of cognitive interventions is to facilitate more adaptive
thinking through cognitive restructuring and behavioral experiments.
COGNITIVE RESTRUCTURING
Cognitive restructuring promotes more
adaptive and realistic interpretations of Through identification of thinking traps,
events by identifying the presence of cognitive restructuring can be used
thinking traps.

These cognitive traps are patterns of

biased thinking that contribute to overly to promote more balanced thinking,
negative appraisals.

encouraging patients to consider

alternative interpretations of circumstances
that are more helpful and less biased by
anxiety.
BEHAVIOURAL EXPERIMENTS

Behavioral experiments
involve encouraging patients Some combination of
to empirically test cognitive restructuring and
maladaptive beliefs to behavioral experiments are
determine whether there is often implemented in CBT
evidence supporting extreme across all anxiety disorders.
thinking.
BEHAVIORAL INTERVENTIONS

There are several behavioural strategies in CBT

for anxiety disorders, yet the central behavioural
strategy is exposure therapy.
EXPOSURE TECHNIQUES
Specifically, heightened
Exposure techniques rely on anxiety and fear prompt
learning theory to explain how individuals to avoid
prolonged fear is maintained over experiences, events, and
time. thoughts that they believe will
lead to catastrophic outcomes.

Continued avoidance of
feared stimuli and events
contributes to the
maintenance of
prolonged anxiety.
EXPOSURE TECHNIQUES

Exposure exercises are designed to After repeated exposures to a feared

encourage a patient to confront a feared situation (e.g., heights) without engaging
situation without engaging in avoidance or in avoidance or safety behaviors (e.g.,
subtle safety behaviours closing one’s eyes to avoid looking
down),
(i.e., doing something to make an anxiety-
inducing situation less distressing).
the patient will learn that such a
situation is less likely to be associated
with disastrous outcomes, and new
experiences of safety will be reinforced.
Similar to the behavioral experiments described in the cognitive
intervention, which test whether a faulty thought is true or false,

exposure exercises offer the opportunity for patients to test their negative
beliefs about the likelihood of a bad outcome by exposing themselves to
whatever situations they have been avoiding.

Thus, cognitive approaches and exposure exercises are complementary

techniques that can benefit individuals with anxiety disorders.
CBT FOR SPECIFIC DISORDERS

Different aspects of CBT will be explored and emphasized as they relate

to specific presentations of anxiety.

CBT approaches have been individualized to specific anxiety disorder

presentations (e.g., panic disorder, specific phobias, social anxiety
disorder).

Each disorder-specific treatment manual is written to consider unique

applications of CBT strategies for the presenting disorder.
PANIC DISORDER

Panic disorder is characterised by: Individuals with panic disorder exhibit

• recurrent, unexpected panic attacks cognitive and behavioral symptoms, such
accompanied by worry and behavioral as-
changes in relation to future attacks. • -catastrophic misinterpretations of their
• Panic attacks are marked by acute, intense symptoms as dangerous (e.g., “my heart
discomfort, with symptoms including heart pounding means I will have a heart attack”) and
palpitations, sweating, and shortness of • avoidance of situations or sensations that induce
breath. panic (4).
• Cognitive-behavioral treatments thus target these
symptoms.
Cognitive restructuring
• used to help patients reinterpret their maladaptive thoughts
surrounding panic (e.g., “if I get dizzy, I will go crazy”) to be more
flexible (e.g., “if I get dizzy, it may just mean that I spun around too
fast”).

Behavioral treatments include

• exposure to the situations (i.e., in-vivo exposure, which might
include driving in traffic or riding the subway) and
• bodily sensations (i.e., interoceptive exposure, which would
include physical exercises to bring on physical symptoms) that
trigger panic in order to reduce the fear and anticipatory
anxiety that maintain the symptoms.
GENERALIZED ANXIETY
DISORDER

GAD is characterized by Treatment for GAD involves:

excessive and uncontrollable • a wholesale approach to target
worry about several life excessive worry with a
domains (e.g., finances, combination of cognitive and
health, career, the future in behavioral strategies (5).
general).
 Cognitive restructuring • to target dysfunctional thoughts, usually further
exercises are emphasized cognitive treatments are included to address worry
throughout the treatment behavior in addition to thought content.

Cognitive techniques, such as • The CBT conceptualization of worry describes worry as

mindfulness, are emphasized to a mental behavior or process, characterized by repetitive
target worrying as a process. negative thinking about catastrophic future outcomes.

Exposure therapy is often

implemented as imaginal
exposures for GAD, because
individuals with GAD rarely have
an external object that is feared.

Cognitive restructuring and imaginal exposure exercises can benefit patients with GAD by targeting
their tendency to give catastrophic interpretations to their worries, whereas mind- fulness can be
helpful in targeting worry as a mental behavior itself (5).
SOCIAL ANXIETY DISORDER

Social anxiety disorder

involves a fear of negative Cognitive restructuring is
evaluation in social The primary treatment used in conjunction with
situations and is approach for social anxiety exposure exercises to
accompanied by anxiety and disorder consists of reinforce the new learning
avoidance of interpersonal exposure exercises to feared and shift in perspective
interactions and social situations (6). occurring through exposure
performance in front of therapy.
others.
OBSESSIVE-COMPULSIVE
DISORDER

(OCD) is characterized by A CBT conceptualization of OCD

considers compulsions as a form of
• obsessions (i.e., unwanted thoughts emotional avoidance.
or images that are intrusive in • Although both cognitive interventions and
nature) and compulsions (i.e., exposure exercises are helpful for
actions or mental behaviors that are individuals with OCD, the latter are often
performed in a rule-like manner to emphasized.
neutralize the obsession. • The gold-standard CBT treatment for OCD
is exposure and ritual prevention therapy
(7).
PHOBIAS
SPECIFIC
PHOBIAS Selective, persistent and out of proportion
• Includes cognition that leads to behavioural response, whether or not the threat is present
• Maintained through the processes of classical and operant conditioning.

SOCIAL
PHOBIAS A more pervasive, highly cognitive type of phobia
• Distinguishing feature is the fear of doing something in front of others
• May be situation or context (e.g. performance versus interaction anxiety) specific
• Fear of one’s own behaviour causing negative attention from others
THERAPEUTIC TREATMENT OF
PHOBIA
Mainly behavioural or cognitive behavioural
techniques are used
• Systematic Desensitisation (with or without relaxation
training)
• Flooding (with or without relaxation training)
• Modelling
• Cognitive restructuring, skills training, gradual
exposure
WHAT CAN YOU DO?
COGNITIVE BEHAVIOURAL
Identify negative thoughts and thinking Activity monitoring – link activity, thoughts
patterns which make you feel unpleasant and feelings
using a thought diary (Appendix A)
Become more active – this leaves you less
Label the type of ‘thinking error’ (Appendix B) time to worry or listen to your negative
thoughts
Develop balanced thinking by looking for
evidence for and against the thoughts and Increase pleasant activities
finding new evidence you might otherwise
Break tasks into small achievable steps
miss
Face your fears – try to break negative cycles
Learn new skills i.e. distraction, positive
by dropping avoidance, escape and safety
self-talk, problem-solving skills
behaviours
 Appendix A

SITUATION FEELING UNHELPFUL AUTOMATIC WHAT ARE THE CHALLENGE ALTERNATIVE THOUGHT HOW MUCH
THOUGHTS THINKING ERRORS? WHAT IS THE EVIDENCE WHATS ANOTHER WAY DO I
HOW MUCH DO I AGAINST THIS OF VIEWING THE BELIEVE MY
BELIEVE THE THOUGHT? THOUGHT? SITUATION? ORIGINAL
THOUGHT
NOW?

Meeting new Anxiety Nobody will like me Black and white thinking I have other friends I am just nervous about 30%
people I believe this 90% Catastrophizing People ask my opinion meeting new people
Mind reading about things Most people get nervous
Thinking Mistakes/Errors

 Arbitrary Inference: Drawing a conclusion in the absence of sufficient evidence. Example: You are involved in a conversation
with an acquaintance. The acquaintance cuts short the conversation and rushes off. You think, “I must be so boring.”

 “YES BUT” thinking: Focusing on one aspect of a situation while ignoring more important and more relevant features. Example:
A friend tells you that you look nice in your new outfit and you say to yourself, “She’s just saying that to be nice ~ she doesn’t
really mean it.”

 Overgeneralization: Applying a conclusion to a wide range of events or situations when it is based on isolated incidents. You find
out that a colleague doesn’t like you, so you conclude that nobody likes you.

 Magnification/Minimization or Black and White Thinking: Enlarging or reducing the importance of events. Minimization is
similar to discounting positives – insisting that positive experiences don’t count. Example: You are on a diet and eat a spoonful of
ice cream and think to yourself, “I’ve blown my diet completely.” Leading to you eating more ice cream

 Personalizing: Relating external events to yourself when there is no obvious basis to do so. Example: You arrive home from
work and your partner is cross and you think to yourself, “I must have upset him/her, it’s all my fault.”

 Catastrophizing: Dwelling on the worst possible outcome of a situation and overestimating the probability that it will occur.
Example: You are due to go to a party at the weekend and say to yourself, “I bet it will be awful, no one will talk to me and I will
look stupid stood all alone.”

 Mind Reading: Assuming people are reacting negatively to you when there is no definite evidence for this. Example: A friend
doesn’t return your call and you say to yourself, “She doesn’t like me anymore, she thinks I’m weird”.

 Emotional Reasoning: You decide how things are on the basis of how you feel. Example: You feel worried about giving a report in
front of your colleagues and say to yourself, “I feel so nervous, everyone will see how nervous I am and something awful will
happen.”

 Labeling: You attach negative labels to yourself and call yourself names. Example: You miss an appointment with the doctor.
Instead of thinking, “I made a mistake,” you say to yourself, “I’m so untrustworthy, I’m stupid.”