Reducing Anxiety and Altering Patterns of Avoidance

Thinking Style in Anxious Patients 

• There is a heightened level of attention to potential threats in the environment 
• Example: A women with fear of airplanes has to fly across the country for work, she believes the plane is likely to crash despite the low risk of this actually occurring.

Predominant thinking patterns in Anxiety 

1. Fears of harm and danger 
2. Increased attention towards potential threats 
3. Overestimation of the risk of situations 
4. Automatic thoughts associated with danger, risk, uncontrollability, incapacity
5. Underestimates of ability to cope with fearful situation 
6. Misinterpretation of bodily stimuli 

Avoidance

• The emotional and physical response to the feared object or situation is so severe that the person will do anything to avoid it. 
• Because the avoidance behavior is rewarded with emotional relief, the behavior is more likely to occur when the person is faced with similar circumstances. 
• Example: A person with anxiety is invited to a party and decides to make up an excuse not to go and the anxiety is relieved. Each time the person is faced with a similar situation they are likely to act the same way. 

CBT Model for Anxiety

1. Unrealistic fear of objects or situations 
2. A pattern of avoidance reinforces the belief that I cannot deal with the feared object or situation 
3. The pattern of avoidance must be broken to overcome the anxiety. 

Behavioral Treatments: 

• There are two general methods of behavior treatment for anxiety 
• Reciprocal inhibition: A process of reducing emotional arousal by helping the person experience a positive or healthy emotion in place of the unhealthy one. (deep breathing, relaxation techniques) 
• Exposure: expose yourself to the stressful situation, fear will occur but cannot be sustained indefinitely and the person will begin to adapt to the situation. 

Assessment of symptoms, triggers, and coping strategies

1. What is the event that triggers the anxiety? 
2. What are the underlying automatic thoughts, cognitive errors, and schema involved in the overreaction to the feared stimulus?
3. What is the emotional and psychological response? 
4. Habitual behaviors such as avoidance?

Cognitive Errors

• Cognitive errors have been found to occur more often in people with depression and anxiety.
• There are 6 main categories of cognitive errors 
• Selective abstraction: A conclusion is drawn after looking at only a small amount of information. Other contradictory information is screened out to confirm the persons biased view of the situation.
• Arbitrary inference: A conclusion is reached in the face of contradictory evidence or lack of evidence
• Overgeneralization: a conclusion is made about one or more isolated incidents and then extended illogically to cover broad areas of functioning.
• Magnification or minimization: The significance of an attribute event or sensation is exaggerated or minimized.
• Personalization: external events are related to oneself when there is little or no evidence for doing so.
• Absolutistic thinking: judgments about oneself, others or personal experiences are placed into one of two categories: All good or All bad

Techniques:

1. Relaxation training: reducing muscle tension induces a state of relaxation and often results in reduced anxiety

• Rate the level of anxiety and muscle tension on a scale of 0 to 100, with 0 being no tension and 100 being max tension 
• Try making a fist and squeezing to a level of 100, then release it to a level of 0. Try doing so with the other hand. Notice that we have voluntary control over how much tension we feel. 
• Starting with the legs tense and release each muscle group working your way up to the head. (I prefer to do this laying down) 
• Try to keep positive mental images in your mind while doing this. Example: picture your tension and worries melting away like ice when left out in the sun. 
• Try doing this daily for 1 week and record how you feel before and after a session.

2. Thought stopping: Stop negative thoughts and replace them with positive adaptive thoughts. 

• Recognize: that a dysfunctional thought pattern is active 
• Give self-instructions to interrupt the thought pattern:  Shift attention away from the anxiety provoking thought. (STOP! Or Don’t go there!) 
• Consider guided images: try to imagine doing something enjoyable, playing a game, watching a sport, going on vacation. This can be combined with muscle relaxation  

3. Distraction: Develop several positive scenes that you can go to when anxious. Examples include walking in a nice park, going to your favorite restaurant, and spending time with friends/family 

4. Decatastrophizing: examine the evidenceto see that the likelihood of adverse outcomes is much less than we estimate

• Estimate the likelihood: of the event occurring. Rate it on a scale of 0 to 100% 
• Evaluate the evidence: for and against the event occurring 
• Review the evidence list: now re-estimate the risk of the event occurring after going through the evidence 
• Create an action plan: brainstorm strategies to reduce the likelihood of catastrophic occurring. Write down actions that you could take to prevent the feared outcome. 
• Develop a plan for coping: if the event should occur. 
• Reassess: compare the original rating to the new rating 
• Debrief: What was good about working through a catastrophic event in this manner?

5. Deep Breathing: 

• Aim for 30-60 breaths, 1-2 cycles
• Start in the sitting position, hands on la or knees 
• Take 10 breathes in through the nose and out through the mouth 
• Take 10 breaths in through the nose and out through the nose 
• Take 10 breaths in through the nose and hold for 5-10 seconds, then release out through the mouth 

6. Exposure: systematically or all at once (flooding) exposing yourself to the feared object or situation. This is the most important part of CBT for anxiety. Systematic desensitization: graded exposure, starting with less anxiety provoking situations 

• Be specific: details matter, “stop being afraid to go to parties” is not specific “go to my neighbor’s house party for 20 minutes and talk to one person” 
• Rate each step on a scale of 0 to 100 depending on how much anxiety you expect to occur 
• Develop at least 8-12 scenarios that go from lowest to highest anxiety 
• Work with the therapist to select to order of steps for graded exposure therapy 
• Two types: imaginal and real-world exposure, depending on the case both may be used (good for OCD and PTSD)