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Specific Phobias & GAD. JONATHAN GASTON DIRECTOR – EMOTIONAL HEALTH CLINIC CENTRE FOR EMOTIONAL HEALTH. Defining Fear/Anxiety. ‘Fight-Flight Response’ A necessary inbuilt protective response mechanism to protect us from danger and help us survive Only a problem when:

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Specific phobias gad

Specific Phobias& GAD

JONATHAN GASTON

DIRECTOR – EMOTIONAL HEALTH CLINIC

CENTRE FOR EMOTIONAL HEALTH


Defining fear anxiety

Defining Fear/Anxiety

  • ‘Fight-Flight Response’

  • A necessary inbuilt protective response mechanism to protect us from danger and help us survive

  • Only a problem when:

    • Mechanism is switched on when we don’t want it to be

      OR

    • The intensity of the response seems ‘out of proportion’ to the actual danger


Physiological anxiety response

Physiological Anxiety Response

  • Rapid heart, heart palpitations, pounding heart

  • Sweating

  • Trembling or shaking

  • Shortness of breath or smothering sensations

  • Dry mouth or feeling of choking

  • Chest pain or discomfort

  • Nausea, stomach distress or gastrointestinal upset

  • Cold chills or hot flushes

  • Dizziness, unsteady feelings, lightheadedness, or faintness

  • Feelings of unreality or feeling detached from oneself

  • Numbing or tingling sensations

  • Visual changes (e.g., light seems too bright, spots, etc.)

  • Blushing or red blotchy skin (especially around face)

  • Muscle tension, twitching, weakness or heaviness


Neurobiology of anxiety stein et al 2007 etkin wager 2007

Neurobiology of Anxiety (Stein et al., 2007; Etkin & Wager, 2007)

  • Amygdala Hyperactivity – central to fear conditioning

  • Insula Hyperactivity– regulates autonomic nervous system and associated with interoceptive awareness


Cbt models anxiety

CBT MODELS & ANXIETY


Traditional a b c model of cbt

‘Traditional’ A-B-C Model of CBT

  • Linear

  • Unidirectional

  • ‘Thoughts cause feelings’

    ABCD

    SituationsThoughts Feelings Behaviour

  • Focus is on challenging irrational thoughts (cognitive restructuring)


More current cbt model

More Current CBT Model

Thoughts

Physiology Mood/Emotion

Behaviour

  • Non-linear

  • Integrative

  • All components of equal importance


Final cognitive pathway model

Final Cognitive Pathway Model

Physiology

(Physical Symptoms)

Mood/Emotion

COGNITION

‘More Conscious’

‘More Automatic’

Behaviour

Perception/Attention

‘Environment’


Cognitive pathway model

Cognitive Pathway Model

  • Cognitive, behavioural, emotional, physiological and attentional approaches are potentially ‘synergistic’ not ‘antagonistic’

  • Humans always employing cognitive processes in solving any problem- whether these processes be more automatic or more conscious in nature

  • Different common pathways (eg., conditioning, observational learning, cognitive challenging, emotional processing, mindfulness) lead to same final common pathway:

    “Action on an underlying cognitive belief structure”


Final cognitive pathway model for anxiety

Final Cognitive Pathway Model for Anxiety

Anxiety Symptoms

‘Fight or Flight’ Response

Anxiety/Fear

& Apprehension

DANGER/THREAT

APPRAISALS

‘Probability’ & ‘Cost’

Safety Behaviours

Avoidance

Escape

Neutralising

Hypervigilance for Danger

‘Scanning for threat’

Look for ‘confirming evidence’

‘Environment’


Aim of treatment for anxiety

Aim of Treatment for Anxiety

“To modify danger/threat appraisals to become more realistic and adaptive”


In designing treatment for anxiety

In Designing Treatment for Anxiety

  • Key in Assessment: What are the specific danger/threat expectancies?

  • Key in Treatment: What factors are currently maintaining the specific danger/threat expectancies?

  • Order of Effectiveness in Learning: (Reiss, 1980)

    • Experience

    • Observation

    • Symbolic (e.g., language)


Cbt for anxiety cognition

CBT for Anxiety - Cognition

  • Key: need to address both probability and cost with some fears

  • Also need to consider ‘Metacognition' - beliefs about the problem itself:

    • problem (causes, maintenance, costs, benefits)

    • utility of current coping strategies (general)

    • specific safety strategies

    • change

    • self-efficacy

    • coping with actual physiological sx. (are sx. harmful?)


Cbt for anxiety behaviour

CBT for Anxiety - Behaviour

  • Key: How is the client's behaviour maintaining their threat appraisals?

  • Safety Behaviours

    • avoidance & escape behaviours

    • proactive (‘neutralising’) behaviours

    • 'subtle' in-sitn. safety behaviours

    • cognitive safety behaviours


Cbt for anxiety physiology emotion

CBT for Anxiety – Physiology & Emotion

  • traditionally a ‘control-based’ approach

  • now less emphasis than previously

  • relaxation can useful as general stress/anxiety reduction tool

  • be careful intervention strategies do not become safety behaviours

  • often treatment (exposure) will involve increasing Sx.

  • ‘symptom surfing’ - increase coping

  • ‘symptom exposure’ – increase tolerance

    ‘short term gain vs. long-term change’


Cbt for anxiety attention

CBT for Anxiety - Attention

  • attentional focus can interfere with the processing of information from feared situations (‘selective filter’)

  • client needs to process 'range' of perceptual evidence

  • 'task-focussed attention'

  • 'mindfulness' (being in the moment)

  • how best to train???


Do psychotherapies produce neurobiological effects kumari 2008

Do Psychotherapies produce Neurobiological effects? (Kumari, 2008)

  • Emerging empirical evidence to demonstrate that psychological therapies produce changes at the neural level

  • Paquette et al., (2003)

    • Successful CBT modified neural activity in the dorsolateral prefrontal cortex and the para-hippocampal gyrus in a group of spider phobics

    • “CBT reduces phobic avoidance by de-conditioning contextual fear learned at the hippocampal/parahippocampal region, and by decreasing cognitive misattributions and catastrophic thinking at the level of the prefrontal cortex”


Specific phobias

SPECIFIC PHOBIAS


Lohr oluntunji sawchuk 2007

Lohr, Oluntunji & Sawchuk (2007)

  • The more explicitly danger is signalled in terms of location, duration, intensity & onset, the more specifiable safety signals can be

  • Specific phobias provide the best example of a danger signal with clearly defined boundaries & properties

  • The safety behaviour of avoidance is often so effective that daily life is only minimally disrupted

  • This may account partially for the significant discrepancy between the high diagnostic prevalence vs. the low proportion seeking treatment (1%)


Specific phobia dsm iv

SPECIFIC PHOBIA - DSM IV

A.MARKED AND PERSISTENT FEAR THAT IS EXCESSIVE OR UNREASONABLE AND CUED BY PRESENCE OR ANTICIPATION OF A SPECIFIC OBJECT OR SITUATION.

B. EXPOSURE TO STIMULUS ALMOST INVARIABLE PROVOKES IMMEDIATE ANXIETY.

C. PERSON RECOGNISES EXCESSIVENESS OF FEAR.

D. STIMULUS AVOIDED OR ENDURED WITH DREAD.

E.AVOIDANCE INTERFERES SIGNIFICANTLY WITH NORMAL ROUTINE OR FUNCTIONING


Specific phobia subtypes

Specific Phobia - Subtypes

ANIMAL – spiders, snakes, other insects, dogs, birds, sharks, etc

NATURAL ENVIRONMENT – storms, heights, water

BLOOD, INJECTION, INJURY – seeing blood or an injury, receiving an injection or invasive medical procedure (common fainting response)

SITUATIONAL – tunnels, bridges, elevators, flying driving, enclosed spaces, driving

OTHER – choking, vomiting, contracting an illness, loud noises, costumed characters


Danger threat appraisals in specific phobias

DANGER/THREAT APPRAISALS IN SPECIFIC PHOBIAS?

  • Pain

  • Physical/bodily harm

  • Illness/Disease

  • Death


Demographics of specific phobia

Demographics of Specific Phobia

  • LIFETIME PREVALENCE12.5%

    (Kessler et al., 2005)

  • AGE OF ONSETYOUNG (ÖST)

    • ANIMAL FEARS - <7

    • BLOOD - <9

    • DENTAL - <12

    • SITUATIONAL (CLAUSTRO)- 20

  • AGE OF PRESENTATION??

  • SEX DISTRIBUTIONFEMALE 2:1 ratio

  • COURSE OF DISORDERUNKNOWN

  • DEGREE OF INTERFERENCELOW

  • COMORBIDITYHIGH WITH OTHER ANXIETY DIS

    (Magee et al., 1996)


Heritability of specific phobias kendler et al 1999

HERITABILITY OF SPECIFIC PHOBIAS – KENDLER ET AL (1999)


Conditioning theory of phobias

CONDITIONING THEORY OF PHOBIAS

CS UCS

AVOID

(DOG)(BITE)

CR UCR

(FEAR) (PAIN/FEAR)


Problems with the conditioning theory of phobias rachman 1970 seligman 1971

PROBLEMS WITH THE CONDITIONING THEORY OF PHOBIAS - RACHMAN (1970), SELIGMAN (1971)

  • MANY AVERSIVE EXPERIENCES DO NOT RESULT IN PHOBIAS (E.G. AIR-RAIDS)

  • PHOBICS DO NOT OFTEN RECALL “CONDITIONING”

  • PHOBIAS DO NOT EXTINGUISH EASILY

  • PHOBIAS OCCUR TO A LIMITED SET OF STIMULI (NO EQUIPOTENTIALITY)


Preparedness theory of phobias seligman 1971

PREPAREDNESS THEORY OF PHOBIAS - SELIGMAN (1971)

A PREPARED STIMULUS IS ONE WHERE:

  • FEAR IS ACQUIRED IN A SINGLE LEARNING TRIAL

  • THE FEAR IS NON-COGNITIVE

  • THE FEAR IS RESISTANT TO EXTINCTION


Support for predictions made by the preparedness theory of phobias mcnally 1987

SUPPORT FOR PREDICTIONS MADE BY THE PREPAREDNESS THEORY OF PHOBIAS (McNALLY, 1987)


Rachman 1976 1977 1991

Rachman (1976, 1977, 1991)

Three (learning-based) Pathways to Fear:

  • Classical conditioning

  • Vicarious acquisition through direct or indirect observations

  • Informational acquisition


Specific threat experiences in height phobia menzies clark 1993

SPECIFIC THREAT EXPERIENCES IN HEIGHT PHOBIA (MENZIES & CLARK, 1993)

A NON-ASSOCIATIVE ACCOUNT OF FEAR ACQUISITION ?


Relationship between falls and fear of heights poulton et al 1998

RELATIONSHIP BETWEEN FALLS AND FEAR OF HEIGHTS (POULTON ET AL, 1998)


Relationship between falls and fear of heights poulton et al 19981

RELATIONSHIP BETWEEN FALLS AND FEAR OF HEIGHTS (POULTON ET AL, 1998)


Cognitive vulnerability model of phobias

Cognitive Vulnerability Model of Phobias


Specific phobia treatment issues

Specific Phobia – Treatment Issues

  • The development of good, well-designed and specific exposure hierarchies

  • Being innovative in planning exposure (e.g., time vs. task)

  • Potential benefits of massed exposure/quick gains ???

  • The client doing enough exposure (dose-response issue)

  • Dealing with the physical sx. of anxiety while doing exposure

  • ‘Subtle avoidance’ which may reduce exposure effect (the case for early ‘guided’ exposure)

  • The case for ‘overlearning’ ???

  • Applied tension for fainting in blood-injury phobia

  • ‘Fear vs. disgust’


Optimising exposure craske et al 2008

Optimising Exposure (Craske et al., 2008)

1. Variability throughout Exposure

  • Retention of learned material is enhanced by random and variable practice

  • While variation increases learning difficulty, it enhances long-term outcome

  • Variation increases the storage strength of information

  • Variation results in pairing the information to be learned with more retrieval cues, this enhancing retrievability

  • Variation leads to superior generalization


Optimising exposure craske et al 20081

Optimising Exposure (Craske et al., 2008)

2. Spacing of Exposure Tasks

  • Temporally spaced learning trials may result in stronger learning acquisition than massed

  • Evidence suggests though that each trial must sufficiently violate fear expectancies

  • ? Massed X Spaced interaction

  • Some evidence for ‘tapering’ (progressively longer intervals between exposure occasions

    3. Context Effects

  • Should conduct exposure therapy in multiple contexts, especially those in which the previously feared stimulus is likely to be encountered once treatment is over


Optimising exposure craske et al 20082

Optimising Exposure (Craske et al., 2008)

4. Fear Toleration vs. Fear Reduction

  • Emotional regulation is potentially dysfunctional when applied rigidly to down regulate emotions through suppression, control, avoidance or escape

  • Persistent attempts to down regulate aversive states are often critical to the onset of phobias and other anxiety disorders

  • Some evidence that sustaining fear responding throughout extinction may actually enhance extinction learning


Generalised anxiety disorder

GENERALISED ANXIETY DISORDER


Lohr oluntunji sawchuk 20071

Lohr, Oluntunji & Sawchuk (2007)

  • The more explicitly danger is signalled in terms of location, duration, intensity & onset, the more specifiable safety signals can be

  • Danger signals that transcend time and place (unpredictability of onset) make for poorly defined safety signal development

  • Danger signals in the form of intrusive thoughts and worries that are future-oriented and involve catastrophic outcomes with objectively low probability do not allow for the establishment of safety relative to current time and place

  • The broad nature of threat will render safety seeking behaviour as ill defined and generalised

  • Is GAD largely a chronic but unsuccessful search for safety ? (Woody & Rachman, 1994)


Gad dsm iv criteria

GAD: DSM-IV Criteria

  • EXCESSIVE ANXIETY AND WORRY OCCURRING MORE DAYS THAN NOT FOR AT LEAST SIX MONTHS ABOUT A NUMBER OF EVENTS.

  • DIFFICULTY CONTROLLING THE WORRY

    C.AT LEAST THREE OF THE FOLLOWING:

    • 1) RESTLESSNESS OR FEELING KEYED UP

    • 2) EASILY FATIGUED

    • 3) DIFFICULTY CONCENTRATING

    • 4) IRRITABILITY

    • 5) MUSCLE TENSION

    • 6) SLEEP DISTURBANCE

      D. FOCUS OF WORRY NOT ANOTHER AXIS 1


Danger threat appraisals in gad

DANGER/THREAT APPRAISALS IN GAD?

Many and varied

Two key underlying issues:

  • The world is an unpredictable and unsafe place

  • I am ill-equipped to deal and cope with this danger and general uncertainty (‘ a poor coper’)

    People with GAD like control and predictability


Definition of worry borkovec et al 1983

DEFINITION OF WORRYBORKOVEC ET AL. (1983)

  • AN ATTEMPT TO ENGAGE IN MENTAL PROBLEM-SOLVING ON AN UNCERTAIN ISSUE WITH A POTENTIAL THREAT OUTCOME


Content of worries in gad roemer et al 1997

CONTENT OF WORRIES IN GAD- ROEMER ET AL (1997)


Content of miscellaneous worries in gad roemer et al 1997

CONTENT OF MISCELLANEOUS WORRIES IN GAD - ROEMER ET AL (1997)


Features of worry in gad craske et al 1989

FEATURES OF WORRY IN GADCRASKE ET AL. (1989)


Gad demographics

GAD - DEMOGRAPHICS

  • GAD has a lifetime prevalence of 5%

  • GAD affects approximately 400 000 adult Australians each year

  • Gender ratio: Females 60%

  • GAD makes the top 12 diseases for disability adjusted life years lost

  • GAD presents a substantial financial cost to the community, e.g., high health care costs and lost work productivity

  • GAD is associated with substantial co-morbidity - primarily other anxiety disorders & depression


Dsm iv disorders and affective structure brown et al 1998

DSM-IV DISORDERS AND AFFECTIVE STRUCTURE – BROWN ET AL (1998)


Life interference

Life Interference

  • GAD interferes with:

    • Work and academic functioning/aspirations

      (over & under achievement)

    • Enjoyment and quality of life

      (chronic cognitive & physical arousal, avoidance)

    • Emotional experience

      (can be aloof or overly-emotional)

    • Engagement in interpersonal relationships

      (stress, intimacy, genuineness, avoidance, isolation)

      Pure GAD is equally as disabling as pure MDD


Course

Course

  • GAD has an early onsetand a chronic course

  • Most people with GAD have always been worriers

  • Mean onset is between the teens and late twenties

  • BUT, onset may be earlier (children were previously diagnosed with “overanxious” disorder)

  • GAD symptoms are chronic and persist for 10 yrs or more

  • GAD is unlikely to remit spontaneously


Probability of remission of gad yonkers et al 1996

PROBABILITY OF REMISSION OF GAD (YONKERS ET AL, 1996)


Contributing factors

Contributing Factors?

  • Genetics, temperament factors, parenting styles

  • Some evidence that people with GAD have more insecure attachment styles– primarily ambivalent

  • Childhood relationships characterized by enmeshment with caregivers – children had inappropriate levels of responsibility (parenting their parents)

  • Some evidence of heightened levels of early trauma

  • These factors impact on:

    • Coping styles and Self-efficacy

    • Enhance vigilance and planning for threat, but feel poorly resourced to deal with actual threat; feeling overwhelmed

    • Enhance fears of uncontrollability and unpredictability

    • Children may internalize beliefs about vulnerability, weakness, inadequacy


Frequency of disorders in 1st degree relatives noyes et al 1987

FREQUENCY OF DISORDERS IN 1ST DEGREE RELATIVES - NOYES ET AL. (1987)


Models of gad

MODELS OF GAD


Worry as emotional suppression borkovec

WORRY AS EMOTIONAL SUPPRESSION - BORKOVEC

  • WORRY COMPLETELY SEMANTIC

  • FULL EMOTIONAL PROCESSING REQUIRES BOTH SEMANTIC AND VISUAL PROCESSING

  • HENCE WHEN WORRY - EMOTIONS PROCESSED AT A “LOWER” LEVEL

  • THUS WORRY USED TO AVOID COMPLETE EMOTIONAL EXPERIENCE

  • IN TURN, EMOTIONAL ISSUES ARE MAINTAINED


Emotional avoidance and regulation 1

Emotional Avoidance and Regulation 1

  • Borkovec’s cognitive avoidance model essentially says that people with GAD fear intense negative emotions

  • But he doesn’t conceptualise this as another threat appraisal that is fuelling worry

  • Instead he argues that worry has a function, that is, it acts as a form of cognitive avoidance that inhibits negative affect through the automatic/unconscious inhibition of imaginal processing

  • This in turn negatively reinforces the use of worry as an emotion regulation strategy, which dampens anxiety in the short term


Emotional avoidance and regulation 2

Emotional Avoidance and Regulation 2

  • Mennin et al. (2002, 2004), following from Borkovec, have suggested that GAD is a disorder of emotion dysregulation involving:

    • Heightened emotional intensity

    • Heightened emotional reactivity

    • Maladaptive emotional management

    • Poor understanding of emotions

Poor tolerance

of emotions

Leading to

emotional

avoidance


Relationship between worry coping anxiety davey 1992

RELATIONSHIP BETWEEN WORRY, COPING & ANXIETY - DAVEY (1992)

  • PARTIAL CORRELATIONS BETWEEN WORRY AND COPING, CONTROLLING FOR TRAIT ANXIETY

  • ACTIVE COGNITIVE COPING.26*

  • ACTIVE BEHAVIOURAL COPING.11

  • AVOIDANT COPING.30*


Cognitive model of gad wells 1995

COGNITIVE MODEL OF GAD(WELLS, 1995)

TRIGGER

POSITIVE META-BELIEFS ACTIVATED (STRATEGY SELECTION)

TYPE 1 WORRY

NEGATIVE META-BELIEFS ACTIVATED

TYPE 2 WORRY

EMOTION

BEHAVIOUR

THOUGHT CONTROL


Type 1 worries wells 1995

TYPE 1 Worries (Wells,1995)

  • Concern external daily events

    • (e.g., health of a partner)

  • Concern non-cognitive internal events

    • (e.g., bodily sensations)


Type 2 worries meta worry wells 1995

TYPE 2 Worries – Meta-worry (Wells, 1995)

  • How people appraise (both positive & negative) the activity and function of worry

  • ‘worry about worry’

  • This meta-worry leads to the client further engaging in Type 1 worry

  • Can broaden concept to use with other anxiety and non-anxiety problems - ‘beliefs clients may hold about their problems’ (origin, nature, maintenance, costs & benefits)

  • Fit/misfit between your treatment model and their implicit model will effect engagement and progress


A threat expectancy integrative model of gad abbott gaston 2003

A THREAT EXPECTANCY (INTEGRATIVE) MODEL OF GAD(Abbott & Gaston, 2003)


Threat expectancy in gad the potential for danger is everywhere

Threat Expectancy in GADThe potential for danger is everywhere!

  • Our model suggests that there are five core categories of threat expectancy that can be activated in GAD

    • Situations themselves are potentially threatening

    • Potential confirmation of negative core beliefs is threatening

    • Affect itself is perceived as threatening

    • The consequences of not coping are seen as threatening

    • Worry process itself is perceived as threatening


Threat affect and neutralizing

Threat, Affect and Neutralizing

  • These ways of perceiving threat may be activated in isolation or in combination, and they all feed the perceived intensity of worry and anxiety

  • Biological/tolerance factors may moderate the actual amount of affect experienced

  • The cognitive and affective experience of anxiety triggers the use of avoidance and safety strategies to control potential threat and aversive experience


Predisposing factors

Predisposing Factors

  • Predisposing factors for GAD include:

    • A genetic predisposition to negative affect

    • Ruminative perseverative cognitive style

    • Intolerance of strong negative affect

    • Early life experiences

    • Parenting styles


Negative core schemas in gad

Negative Core Schemas in GAD

  • Predisposing factors lead to the development of underlying schema. Themes of negative schema in GAD seem to include beliefs like:

    • I am defective

    • I am vulnerable

    • I am weak

    • I am inadequate/incompetent

    • I am worthless

  • According to the model, these underlying negative schema drive threat expectancies in GAD


Te1 inflated perceptions of situational threat

TE1. Inflated Perceptions of Situational Threat

  • Overestimate the probability of negative events occurring

    AND

  • Overestimate the cost of negative events, should they occur

    AND

  • Underestimate their ability to cope, should a negative outcome occur


Intolerance of uncertainty dugas et al 2004

Intolerance of Uncertainty (Dugas et al., 2004)

  • People with GAD find uncertainty threatening

    • fearing and avoiding situations with ambiguous outcomes

    • preferring the occurrence of a negative outcome to it’s possibility

    • Only situations that are perfectly controlled are safe

  • But, uncertainty is certainly inevitable!

  • Anxiety about uncertainty is closely linked to fears about unpredictability & uncontrollability and positive beliefs about worry

    “If I am in control and know what will happen,

    then I can prevent negative outcomes”

    “worry helps me do this”


Intolerance of uncertainty and worry dugas et al 1997

INTOLERANCE OF UNCERTAINTY AND WORRY - DUGAS ET AL. (1997)


Te2 confirmation of beliefs about the self

TE2. Confirmation of Beliefs about the Self

  • Anxiety is also experienced when there is the potential for negative core beliefs to be confirmed

    • e.g., Doing an exam will be anxiety-provoking if you believe it may confirm beliefs about inadequacy

  • In response to the anxiety, clients use safety strategies, like perfectionism

    • e.g., Engaging in non-stop studying to prevent potential failure

    • e.g., Last minute studying allows a more palatable “excuse” should failure occur

  • Potentialconfirmation of beliefs triggers anxiety

  • Perceivedconfirmation of beliefs triggers low mood


Te3 meta beliefs about affect

TE3. Meta-beliefs about Affect

  • Negative affect is perceived as threatening in GAD because it is experienced as overwhelming and distressing

  • The experience of intense affect triggers attempts at avoidance or neutralizing

  • Emotions that may be perceived as threatening:

    • Fear and Anxiety

    • Anger

    • Depression

    • Positive affect?


Te4 meta beliefs about coping

TE4. Meta-beliefs about Coping

  • The perceived consequences of not coping with negative outcomes is also seen as threatening

  • For example, If I can’t cope with the feared event, does that mean:

    • I am a failure?

    • I am irresponsible?

    • It’s my fault?

    • I am a bad person?

    • I can’t tolerate these feelings of guilt …

  • People with GAD hold rigid standards about coping – they should cope perfectly, without any distress


Te5 meta beliefs about cognition worry is threatening

TE5. Meta-beliefs About Cognition - Worry is Threatening

  • People with GAD hold strong beliefs that the process of worrying is dangerous to them (e.g., Wells, 1997)

  • If you believe that worry is harmful then you will probably spend a lot of time monitoring your thoughts, trying not to worry, and engaging in a range of associated safety strategies (e.g., checking physical symptoms; thought suppression)


Examples of negative meta worries

Examples of Negative Meta-worries

  • My worrying is uncontrollable

  • Worrying is harmful to me

  • I could “go crazy” from worrying

  • My worries will take over and control me

  • I could get into a state of worrying and then never be able to stop

  • If I worry too much I could lose control

  • Worrying makes me physically sick and puts stress on my body

  • If I don’t control my worry then it will control me

  • If I worry it means I am a weak person

  • People will respect me less if they find out about my worry

  • My worry is harmful to others (eg family members)


Avoidance proactive safety strategies trying to feel safe and in control

Avoidance & Proactive Safety Strategies – ‘Trying to Feel Safe and In Control’

  • The experience of intense negative affect triggers the use of behavioural, cognitive and emotional safety strategies

    • Perfectionistic behaviour may be triggered if not doing well on a task confirms beliefs about inadequacy

    • Engaging in frequent attempts to suppress worries may be triggered by beliefs that worry is harmful

  • People with GAD use a large array of safety strategies to try and control potential negative outcomes and so they can feel safe


Some safety strategies

Some Safety Strategies

Behavioural

Reassurance seeking

Controlling others, situations, feelings

Perfectionism

Over-responsibility

Busyness

Procrastination

Avoiding uncertainty

Avoiding triggers

Cognitive

Thought suppression

Shifting, narrowing attention

Distraction

Checking symptoms

Positive meta-beliefs about worry??

Rumination??

Emotional

Repression

Dissociation

Numbing

Emotional blunting


Effects of using safety strategies

Effects of Using Safety Strategies

  • Safety strategies provide some relief from anxiety in the short-term by exerting a dampening effect on anxiety

  • But, safety strategies reinforce negative underlying schema and threat expectancies in the long term by:

    • Preventing disconfirmation of beliefs about threat

    • Providing some confirmation for beliefs about threat


Treating gad

TREATING GAD


Standard cbt components

Standard CBT Components

  • Psychoeducation about anxiety

  • Detecting triggers and early warning signs

  • Implementing alternative coping strategies

  • Teaching realistic thinking skills

  • Teaching relaxation skills

  • Teaching problem solving/stress-reduction skills

  • Graded exposure (e.g., to worry triggers)

  • Exposure to worry

  • Worry time


Treatment reality

Treatment Reality

  • Research has shown that CBT is effective at reducing anxiety for sufferers. But the outcome data is not so impressive and we can still do a lot better

  • “After 16 years of concerted effort, applications of behavioral and cognitive therapy techniques for treating this anxiety disorder continue to fail to bring about 50% of our clients back to within normal degrees of anxiety” (Borkovec, 2002, p.76)


What should we address in therapy

What Should We Address in Therapy?

  • Myriad of threat expectancies

  • Underlying negative schemas

  • The multitude of safety strategies that are in place to neutralize or avoid potential threat

  • Particularly important to address the avoidance of intense affect and to facilitate the completion of emotional processing


Acceptance mindfulness based approaches

Acceptance & Mindfulness-based Approaches

  • Premise: ‘We compound our suffering by trying to avoid it’

  • Mindfulness is a strategy for gradually turning the client’s attention toward the fear (external and/or internal) as it is happening and exploring it in detail with increasing degrees of acceptance

  • Gradual shift in client’s relationship to anxiety from avoidance to tolerance to acceptance

  • Mindfulness is an awareness of, rather than thinking about, mental events - implying acceptance


Acceptance mindfulness based approaches1

Acceptance & Mindfulness-based Approaches

  • The overarching goal is to reorient clients away from maladaptive attempts to alter their thoughts and feelings, and toward making positive, sustained behavioural change that is consistent with one’s values & goals - essentially to live better rather than to think and feelbetter


Current questions

Current Questions ???

  • Control approach vs. acceptance approach ?

  • Can we integrate mindfulness/acceptance with CBT ???


My contact details

My Contact Details

Jonathan Gaston

Director – Emotional Health Clinic

Centre for Emotional Helath

Phone: (02) 9850 8323

Fax: (02) 9850 6578

Mobile: 0407 221 334

Email:[email protected]

Office:Room 605, Building C3B


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