Treatments for Anxiety

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Treatments for Anxiety. Stacy Shaw Welch, PhD Anxiety and Stress Reduction Center (ASRC) of Seattle June 2, 2010 FCAP Seminar Series / Partners for our Children. Overview. Part 1 – Understanding anxiety Part 2 – Treating anxiety: First line treatment approaches for anxiety
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Treatments for AnxietyStacy Shaw Welch, PhDAnxiety and Stress Reduction Center (ASRC) of SeattleJune 2, 2010FCAP Seminar Series / Partners for our ChildrenOverview
  • Part 1 – Understanding anxiety
  • Part 2 – Treating anxiety: First line treatment approaches for anxiety
  • Part 3 – Concepts of Modular Treatment (moving from Evidence Based Treatment to Evidence Based Practice)
  • Part 4 - Introduction to Modules for Anxiety Treatment
  • Fear, Anxiety, and Anxiety DisordersWhat is anxiety?
  • Fear: focused response to a known or definite threat
  • Fight or flight response
  • Necessary for survival
  • Anxiety: fear response in the absence of clear danger (anticipation or possibility)
  • Universal experience / wide range of normal
  • Can be useful/ functional
  • What is an anxiety disorder?
  • Persistent anxiety over time around situations that are not objectively dangerous / anxiety not appropriate to developmental level
  • Causes
  • Marked distress
  • Impairment in functioning
  • Note: this can be obvious or more subtle in children (e.g., family system is organized around child’s anxiety)
  • Anxiety vs. Anxiety Disorder
  • More a matter of degrees
  • Example of separation anxiety:
  • Normal / functional at specific developmental stages
  • Some children show increased S.A. as a result of traumatic conditioning
  • Some children show increased S.A. with no traumatic conditioning
  • Some children would have such severe or longlasting symptoms that it would meet criteria for a disorder
  • Anxiety disorders
  • Separation anxiety disorder
  • Specific phobia
  • Social phobia
  • Panic disorder/agoraphobia
  • Generalized anxiety disorder (GAD)
  • Posttraumatic stress disorder (PTSD)/ Acute stress disorder (ASD)
  • Obsessive compulsive disorder (OCD)
  • Development of Anxiety
  • Biology + learning
  • Genetics, temperament clearly influence who becomes anxious
  • Environment powerful source of learning and continued “wiring” of the brain to either anticipate
  • lack of control and danger or
  • safety and resources to cope
  • Transaction between the two continues over the lifespan –this is the tragedy and great hope
  • Development of Anxiety
  • Another important transaction: the interaction of anxious behaviors and the environment
  • Anxiety “pulls” for certain behaviors from the environment
  • These environmental responses can further reinforce anxiety and prevent corrective learning experiences
  • Treating Anxiety: Brief Review of ResearchTreatment
  • Two main treatment approaches for children, teens and adults
  • CBT – by far most well researched and effective treatment for anxiety. Should be first-line intervention, combined with meds for moderate or severe disorder.
  • Medication – SSRIs first, then augmentation strategies
  • What is CBT? -Skills based, problem-solving, very practical approach to emotionally driven problems/behaviors-Patients learn to take “bite-sized” small steps towards health-Biopsychosocial model as opposed to purely biomedical model Should include at least 4 elements: education/monitoring, tools to calm physiology, cognitive restructuring, exposureWhat kinds of problems can it be used for? Think behavior change, esp. emotionally driven behaviors
  • Depression *
  • Anxiety disorders**
  • Unexplained medical illness / somatization
  • Chronic pain management
  • Eating disorders (bulimia and binge eating)
  • Insomnia (primary and secondary)
  • Addictions
  • Non-adherence to medical recommendations
  • Lifestyle / Behaviors linked to chronic disease care (physical activity, diet, social support, medications, etc.)
  • Child internalizing and depressive disorders**
  • Marital distress
  • Anger
  • Specific Approaches to Anxiety Treatment
  • Adults: a manual (or two, or three) for each anxiety disorder
  • Children: Not much until 1980’s (DSM-III)
  • Early approaches: adult techniques and theories with child-language
  • Major studies / treatments to know:
  • CBT for anxiety: “Coping Cat”, “Coping Koalla (Kendall, Barrett)
  • Talking Back to OCD: ERP (March), POTS
  • CAMS (meds plus CBT)
  • TFCBT – Trauma – focused CBT
  • Modular treatments emphasizing exposure (Chorpita)
  • Conceptual framework for Modular Treatment of AnxietyModular treatment
  • Addressing what happens when you try to apply evidence based treatment in community settings with
  • Complex clients
  • Complex situations
  • Logistical challenges (e.g., time)
  • Evidence-based treatmentsvs. practice
  • Evidence-based treatments
  • “interventions or techniques that have produced therapeutic change in controlled trials”(Kazdin, 2008)
  • Evidence-based practice
  • “clinical practice that is informed by evidence about interventions, clinical expertise, and patient needs, values, and preferences and their integration in decision making about individual care”(Kazdin, 2008)
  • Protocol-based treatment
  • Strong trend over the last 25 years toward the development of standardized, protocol-based treatments (i.e., treatment manuals)
  • Protocol characteristics:
  • Disorder specific
  • Step-by-step list of interventions
  • Same set of procedures across clients
  • Dissemination and training is generally needed for each protocol
  • Pros and cons
  • Pros
  • Significant advances in the scientific study of psychotherapy (treatments are replicable)
  • Improved treatment outcomes
  • Greater consistency and quality of care
  • Cons
  • Problems with dissemination
  • Overlap and redundancy across protocols
  • Multiple protocols for the same disorder
  • Don’t address co-morbidity
  • Decreased flexibility in treatment
  • Encourage disorder-specific thinking
  • Modular-based treatment
  • Emerging trend in recent years toward more modular, flexible approaches to treatment
  • Modular approaches provide a set of overarching principles and a set of evidence-based interventions (“modules”)
  • Not all modules are necessarily used with each client and the order of modules may vary from client to client
  • Decisions about which modules to use and in what order are based on the unique symptom patterns of each client
  • Modular treatment and anxiety
  • Anxiety disorders lend themselves well to a modular treatment approach because…
  • They share many of the same features and symptoms
  • A CBT conceptualization of anxiety can be applied across the disorders
  • There is considerable overlap in the interventions that comprise the treatment protocols for the various disorders
  • Modular approaches have been developed for treating anxiety in children/adolescents (Chorpita, 2006) and somewhat with adults (Barlow et al., 2004; Sullivan et al., 2007)
  • Basic CBT model of anxietyPhysical sensations(physiological arousal)AnxietyBehaviors (avoidance, safety behaviors)Thoughts(perception of threat)Safety behaviors
  • Anxious people often engage in a range of behaviors to make themselves feel safer when they cannot avoid anxious situations
  • These behaviors are attempts to neutralize feelings of anxiety
  • Although these behaviors can facilitate functioning, they also prevent recovery
  • Examples
  • Reassurance seeking
  • Over-preparation
  • Behavioral rituals
  • Safety cues/objects
  • Integrated CBT Model of Anxiety DisordersFear Stimulus(trigger or cue)Misinterpretation of ThreatPre-existingBeliefsAnxietyEnvironmentalFactorsAvoidant Coping(primary and secondary)Absence of Corrective Experience and LearningComponents of the model
  • Fear stimulus/trigger
  • Anxiety is almost always cued
  • Misinterpretation of threat
  • Primary cognitive distortions in anxiety
  • (1) Overestimating the likelihood of negative outcomes (2) Catastrophizing
  • Avoidant coping
  • Primary avoidance – avoiding triggers altogether
  • Secondary avoidance – engaging in safety behaviors when complete avoidance is not possible
  • Absence of corrective learning
  • New learning does not occur and the fear is maintained (and often strengthened)
  • Separation anxiety disorder- Separating from parent at school.- Going to a friend’s house for a sleep-over.Fear Stimulus(trigger or cue)- My mom/dad might die.- Something bad might happen to my mom/dad.Misinterpretation of Threat- Panic symptoms, cryingAnxiety
  • Primary avoidance: Refuse to leave house/car;
  • call home to be picked up
  • Secondary avoidance: Separates but only if can
  • call parent repeatedly to seek reassurance that
  • he/she is okay; has to carry cell phone at all times
  • Avoidant Coping(primary and secondary)Absence of Corrective Experience and LearningSpecific phobia (flying)
  • Needing to fly for a business trip.
  • Needing to fly for a family vacation.
  • Fear Stimulus(trigger or cue)
  • Something will go wrong with the plane.
  • The plan will crash and I will die.
  • Misinterpretation of Threat- Increased heart rate, shallow breathingAnxiety
  • Primary avoidance: Avoid going on the trip; get
  • someone else to attend the business meeting;
  • family drives to vacation spot instead of flying
  • Secondary avoidance: Sit next to “safe” person;
  • distract self for entire flight; seek reassurance
  • from others about airline safety; drink alcohol or
  • take Xanax before/during the flight (adults)
  • Avoidant Coping(primary and secondary)Absence of Corrective Experience and LearningSocial phobia
  • Having to give a presentation in front of the class.
  • - Needing to ask a question in a store.
  • Fear Stimulus(trigger or cue)
  • I will sound stupid. My mind will go blank.
  • I will be an inconvenience. He will be annoyed.
  • Misinterpretation of Threat- Increased heart rate, sweating, lightheadedAnxiety
  • Primary avoidance: Skip class; avoid asking the
  • question
  • Secondary avoidance: Look down at notes during
  • the entire presentation; talk quickly; over-prepare
  • for presentation; overly apologetic when asking
  • question
  • Avoidant Coping(primary and secondary)Absence of Corrective Experience and LearningPanic disorder
  • Exercising and heart rate starts to increase.
  • Fear Stimulus(trigger or cue)
  • I am going to have a heart attack.
  • I am going to pass out.
  • Misinterpretation of Threat
  • Panic symptoms (increased heart rate, shallow
  • breathing, sweating, dizziness)
  • Anxiety
  • Primary avoidance: Stop exercising; leave the gym
  • Secondary avoidance: Repeatedly check heart
  • rate; call doctor office; go to urgent care center;
  • seek reassurance from friend; carry water and cell
  • phone at all times at gym
  • Avoidant Coping(primary and secondary)Absence of Corrective Experience and LearningGAD
  • Trying to call spouse and he/she is not answering.
  • Fear Stimulus(trigger or cue)
  • Something must have happened.
  • He/she was in an accident.
  • Misinterpretation of Threat
  • Restlessness, muscle tension, increased heart
  • rate
  • Anxiety
  • Primary avoidance: N/A
  • Secondary avoidance: Repeatedly calling spouse
  • at multiple numbers (work, cell phone) until
  • reaching him/her; keep busy and try to distract self
  • until spouse is home
  • Avoidant Coping(primary and secondary)Absence of Corrective Experience and LearningPTSD (sexual assault)
  • Walking home from bus stop after work at dusk.
  • Fear Stimulus(trigger or cue)
  • I am not safe.
  • - Someone could assault/rape me on the way home.
  • Misinterpretation of Threat
  • Increased heart rate, shallow breathing,
  • upset stomach
  • Anxiety
  • Primary avoidance: Avoid taking the bus; drive to
  • and from work; call someone for a ride
  • Secondary avoidance: Have someone walk with
  • him/her between bus stop and home; talk on cell
  • phone during entire walk home; walk quickly; carry
  • pepper spray in hand during walk
  • Avoidant Coping(primary and secondary)Absence of Corrective Experience and LearningOCD (checking)
  • Turning off the stove after cooking breakfast.
  • Fear Stimulus(trigger or cue)
  • What if I left the stove on?
  • It could burn down the house.
  • Misinterpretation of Threat
  • Increased heart rate
  • Anxiety
  • Primary avoidance: Avoid eating breakfast foods
  • that require using the stove
  • Secondary avoidance: Repeatedly check the stove
  • before leaving the house; drive back home mid-
  • day from work to check the stove; call neighbor to
  • check on the house; mentally review memory of
  • turning off the stove throughout the day
  • Avoidant Coping(primary and secondary)Absence of Corrective Experience and LearningShared processes to target
  • There are a set of anxiety processes that are important to target regardless of which anxiety disorder is being treated
  • Maladaptive thoughts that contribute to perceptions of threat in safe situations
  • Physiological reactivity in response to fear triggers
  • Avoidance behaviors that prevent the habituation of fear
  • Safety behaviors that prevent new learning
  • Problematic reinforcement of anxiety by the environment
  • Good news…We have very effective CBT interventions for the processes common to the anxiety disorders!Modular treatment for anxiety
  • A modular CBT approach to treating anxiety involves…
  • Assessing which anxiety processes are most prominent for each client
  • Selecting the evidence-based interventions (“modules”) that are effective for treating these processes
  • Sequencing these modules to address the unique characteristics of each client and his/her environment
  • CBT “modules” for anxiety
  • Psychoeducation
  • Self-monitoring
  • Relaxation skills
  • Cognitive restructuring
  • Response prevention
  • Exposure*
  • Parenting techniques
  • Changing environmental
  • contingencies/responses
  • Relapse prevention
  • Others: social skills, emotion regulation, behavioral activation, motivational interviewing….
  • Flexible modulesFlowchart for a standard manualized CBT protocolFearLadderLearning aboutAnxietyRelaxationCognitive RestructuringExposureRewards / PracticeMaintenanceFinishModular CBT protocol – (Just get to Exposure)Fear Ladder InterferenceLearningaboutAnxietychild readyto practice?noyesin vivopossible?yesnoyesIn VivoExposureImaginalExposuremore items to practice?
  • Maintenancee
  • FinishnoModular flowchart for treatment planningFear Laddermoderatedisruptivebehavior?parents rewardingavoidance?lowmotivation?othermild disruptiveBehavior?negative beliefs ordepression?social skillsdeficits?troubleshootLearningaboutAnxiety
  • Rewards
  • Time-Out
  • Social Skills:
  • Meeting
  • People
  • bright, verbal,
  • or older?
  • yeschild readyto practice?
  • Active
  • Ignoring
  • no
  • Cognitive
  • Restructuring:
  • Probability
  • Social Skills:
  • Nonverbal
  • noyesin vivopossible?
  • Cognitive
  • Restructuring:
  • STOP
  • Cognitive
  • Restructuring:
  • Catastrophic
  • yesnoyes
  • In Vivo
  • Exposure
  • Imaginal
  • Exposure
  • more items to practice?
  • Maintenance
  • FinishnoModular flowchart for treatment planningFear Laddermoderatedisruptivebehavior?parents rewardingavoidance?slowmotivation?othermild disruptiveBehavior?negative beliefs ordepression?social skillsdeficits?troubleshootLearningaboutAnxietyRewardsTime-OutSocial Skills:MeetingPeoplebright, verbal,or older? yeschild readyto practice?ActiveIgnoringnoCognitiveRestructuring:Probability Social Skills:Nonverbalnoyesin vivopossible?CognitiveRestructuring:STOPCognitiveRestructuring:CatastrophicyesnoyesIn VivoExposureImaginalExposuremore items to practice?MaintenanceFinishnoCBT “modules” for anxiety
  • Psychoeducation
  • Self-monitoring
  • Relaxation skills
  • Cognitive restructuring
  • Response prevention
  • Exposure*
  • Parenting techniques
  • Changing environmental
  • contingencies/responses
  • Relapse prevention
  • Others: social skills, emotion regulation, behavioral activation, motivational interviewing….
  • Flexible modulesPsychoeducation
  • Key to helping clients understand their symptoms and the treatment model
  • Psychoeducation should include both:
  • Disorder specific information
  • Review of the integrated CBT model of anxiety
  • Helpful to fill out the model with the client using examples from his/her life
  • Kids- maps, posters, etc.
  • Could be used for anxiety disorder or “normal” anxiety (will be validating if not anxiety reducing)
  • Could be used for parents dealing with anxiety, even without anxiety disorder
  • Integrated Model of Anxiety -Client HandoutFear Stimulus(trigger or cue)Misinterpretation of ThreatPre-existingBeliefsAnxietyEnvironmentalFactorsAvoidant Coping(primary and secondary)Absence of Corrective Experience and LearningSelf-monitoring
  • Critical part of problem/ symptom assessment
  • Helps client recognize the different components of their anxious reactions (“anxiety is not a lump”)
  • Helps clients identify patterns in responses
  • Elements of self-monitoring for anxiety include:
  • Triggers/cues for anxiety
  • Intensity ratings for anxiety (SUDS)
  • Physical sensations
  • Anxious thoughts
  • Anxious behaviors (avoidance, safety behaviors)
  • Young kids would do with caretaker
  • Self-monitoring example - panicSelf-monitoring example - OCDRelaxation
  • Relaxation skills target physiological reactivity associated with anxiety and worry
  • Two main skills are
  • Diaphragmatic breathing – targets acute panic/anxiety reactions
  • Progressive muscle relaxation – targets chronic muscle tension associated with ongoing anxiety/worry
  • Important to be realistic about how effective these skills are in reducing anxiety
  • Could be taught for anxiety disorder or “normal” anxiety
  • Creative ways to teach children (bubbles, snake, tire)
  • Relaxation
  • Disorder specific recommendations
  • Breathing re-training is a standard part of treatment for panic disorder
  • PMR is a standard part of treatment for GAD
  • Neither tends to work that well for OCD
  • General recommendations
  • Consider using with children and adolescents regardless of disorder
  • Consider using with adults regardless of disorder when physiological symptoms are prominent and/or interfere with treatment
  • Coach clients not to use relaxation skills during exposure exercises
  • ExposureExposure is staying present with the feared stimulus long enough for new learning to occur(assuming that fear is not really dangerous)Habituation and anxietyAnxietyTimeExposureThree golden rules of exposure:
  • 1. Fears are faced gradually, moving from least to most difficult
  • 2. The client must stay in the feared situation long enough to learn that the bad things s/he fears will not happen.
  • If withdrawal occurs to quickly-fear can increase
  • 3. Practice and repetition are the keys to success
  • If withdrawal occurs to quickly-fear can increase
  • Exposure
  • Process of exposure is similar across the anxiety disorders, what varies is the fear trigger
  • Separation anxiety – separation from caregiver
  • Specific phobia – feared object/ situation
  • Social phobia – social/performance situations
  • Panic/agoraphobia – physical sensat
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