Treatments for Anxiety

1. 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

2. Overview • 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

3. Fear, Anxiety, and Anxiety Disorders

4. What 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

5. 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)

6. 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

7. 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)

8. 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

9. 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

10. Treating Anxiety: Brief Review of Research

11. Treatment • 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

12. 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, exposure

13. What 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

14. 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)

15. Conceptual framework for Modular Treatment of Anxiety

16. Modular 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)

17. 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)

18. 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

19. 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

20. 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

21. 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)

22. Basic CBT model of anxiety Physical sensations (physiological arousal) Anxiety Behaviors (avoidance, safety behaviors) Thoughts (perception of threat)

23. 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

24. Integrated CBT Model of Anxiety Disorders Fear Stimulus (trigger or cue) Misinterpretation of Threat Pre-existing Beliefs Anxiety Environmental Factors Avoidant Coping (primary and secondary) Absence of Corrective Experience and Learning

25. Components 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)

26. 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, crying Anxiety • 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 Learning

27. Specific 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 breathing Anxiety • 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 Learning

28. Social 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, lightheaded Anxiety • 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 Learning

29. Panic 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 Learning

30. GAD • 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 Learning

31. PTSD (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 Learning

32. OCD (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 Learning

33. Shared 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

34. Good news… We have very effective CBT interventions for the processes common to the anxiety disorders!

35. 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

36. 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 modules

37. Flowchart for a standard manualized CBT protocol Fear Ladder Learning about Anxiety Relaxation Cognitive Restructuring Exposure Rewards / Practice Maintenance Finish

38. Modular CBT protocol – (Just get to Exposure) Fear Ladder Interference Learning about Anxiety child ready to practice? no yes in vivo possible? yes no yes In Vivo Exposure Imaginal Exposure more items to practice? • Maintenancee Finish no

39. Modular flowchart for treatment planning Fear Ladder moderate disruptive behavior? parents rewarding avoidance? low motivation? other mild disruptive Behavior? negative beliefs or depression? social skills deficits? troubleshoot Learning about Anxiety • Rewards • Time-Out • Social Skills: • Meeting • People bright, verbal, • or older? yes child ready to practice? • Active • Ignoring no • Cognitive • Restructuring: • Probability • Social Skills: • Nonverbal no yes in vivo possible? • Cognitive • Restructuring: • STOP • Cognitive • Restructuring: • Catastrophic yes no yes • In Vivo • Exposure • Imaginal • Exposure more items to practice? • Maintenance Finish no

40. Modular flowchart for treatment planning Fear Ladder moderate disruptive behavior? parents rewarding avoidance? slow motivation? other mild disruptive Behavior? negative beliefs or depression? social skills deficits? troubleshoot Learning about Anxiety Rewards Time-Out Social Skills: Meeting People bright, verbal, or older? yes child ready to practice? Active Ignoring no Cognitive Restructuring: Probability Social Skills: Nonverbal no yes in vivo possible? Cognitive Restructuring: STOP Cognitive Restructuring: Catastrophic yes no yes In Vivo Exposure Imaginal Exposure more items to practice? Maintenance Finish no

41. 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 modules

42. Psychoeducation • 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

43. Integrated Model of Anxiety - Client Handout Fear Stimulus (trigger or cue) Misinterpretation of Threat Pre-existing Beliefs Anxiety Environmental Factors Avoidant Coping (primary and secondary) Absence of Corrective Experience and Learning

44. Self-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

45. Self-monitoring example - panic

46. Self-monitoring example - OCD

47. Relaxation • 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)

48. 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

49. Exposure Exposure is staying present with the feared stimulus long enough for new learning to occur (assuming that fear is not really dangerous)

50. Habituation and anxiety Anxiety Time