Explore the role of beliefs and behaviours in maintaining anxiety difficulties

Consider cognitive behavioural interventions used with anxiety.

Anxiety is a response to facing a challenging or threatening situation. If a person perceives that they are under threat their body rapidly produces adrenaline that primes them to respond to this threat.

What are the classic behavioural responses in these types of situation?

(Westbrook et al 2001)

The classic behavioural responses in this type of situation are fight (challenging the threat directly), or flight (escaping or avoiding the threat), although freeze (being physically or mentally immobile) is another possible reaction. (Westbrook et al 2001)

Flight/fightHeart Races,

Thoughts

Feelings

Behaviour

Physical

4 components:

Recognition of danger focus on danger

Run away , freeze, Attack

The continuum principleEmotional problems arise from exaggerated versions of Normal process

A sense of threat Overestimation of harm or danger occurring

Hypervigilance to cues   Focus on threat Rumination and Excessive focus on the threat Persistent threatening Thoughts and images of the Threat. Increased heart rate palpitations   Changes to digestive system nausea/ vomiting   Increased breathing dizziness light headed derealisation

(A potential focus for further anxious predictions)

:

Thoughts

Mood

Behaviour

Physical

Overestimate likelihood of the harm or danger occurring ( Threatening imagery)Underestimate ability to cope ruminate

Palpitations, Vomitingdizzyness

Avoidance , escape.Seek reassuranceprocrastinate , checking( safety behaviours)

Fight or flight

Irritable, anxious

Environment: Perception of threat

Trigger

Perceived threat

Problem response : thoughts,

behaviour and or physiology

Fear is unchallenged

Fear remains in tact: belief unchanged

Trigger

AcuratelyPerceived

threat

Alternative response;

behavioural experiment

Fear is challenged

Old belief changes to a realistic belief

Cycle disrupted

Behavioural principleWhat we do is crucial in maintaining or in changing psychological states

Panic Disorder Generalised Anxiety Disorder Social anxiety Obsessive Compulsive Disorder Post Traumatic Stress Disorder Health Anxiety/Hypochondriasis Specific Phobias

Symptoms of anxiety are a major component of all these disorders

The types of threat or danger with in a situation that serves as a trigger for anxiety, varies between anxiety disorders.

A persistent irrational fear of an object or situation (5 categories: animals, blood injury/injections, situational, uncommon or atypical)

Physical arousal and high levels of anxiety experienced when confronted with the feared object or situation

Accompanied by avoidance

Thoughts

EmotionANXIETY

Behaviour

Physiological

Environment

Summer months: outdoor activities , possibility of wasps !!( hypervigilance)

Wasps will attack/harm me by flying into my ears. If I see a wasp i will pass out.

(Feared consequences& anxious predictions)

Cover ears and Run away

Heart racingHot Shaky

Behavioural Experiments Involve testing predictions about physical, social or

psychological danger Focus is on belief change through experience Experiment must have a clear hypothesis from client,

followed by a task that tests out that belief in an appropriate setting

E.g. If I don’t wash all my food thoroughly, I’ll get food poisoning. Eat some unwashed food, wait and see what happens.

Target cognition: If I see a wasp I will Pass out

Alternative perspective: If I see a wasp ,i may experience anxiety symptoms but i will not pass out

Experiment: look at pictures of wasps increasing in size, rate anxiety every few minutes. Encouraged to drop safety behaviours such as looking a way. Focus on bits of wasp.

Result: Did’nt pass out, anxiety reduced after 20 minutes. Belief in target cognition gradually fell to 15%, while his belief in alternative perspective increased to 80%.

Target cognition: Wasps will always attack me and fly into my ears and harm me....

Alternative perspective: wasps can sting but do not attack people or generally fly into ears to cause harm

Experiment: Ask others if this has ever happened to them, construct a survey of questions eg, how often do you play, eat outside, have you ever been stung by a wasp? If so where? Has a wasp ever flown into you ear? What happened ?

Result:??

James (now 37) has always had a fear of spiders. He remembers hearing a story when he was a child that a spider bit someone and this grew in to a lump. Some time later the lump “hatched and hundreds of baby spiders crawled out”. When he was 6 he recalls that an aunt attempted to help him overcome his fears with a toy rubber spider and kept on putting it down his underpants. He was petrified and every time he pulled the toy out she would hold him down and again place it in his pants. His mother finally intervened and stopped the ‘intervention’.

When he sees a live spider he feels anxious and removes him self from the situation and insists on someone removing the spider before he can enter the room. If he is at home alone he calls friend to come and remove the spider, if no ones around he will shut the door on that room and not go in there for days. He believes that if you kill a spider 10 will come back. When he goes into the garden he scans and looks for webs and spiders. Before going to bed he checks his bed to make sure no spiders are hiding between the sheets. When he stays away from home on the first might he asks his girlfriend to check the room for him while he stands behind her. They do not stay in old B&B but when away in the UK would only stay in modern buildings, e.g., travel lodge, James hates feeling anxious about spiders and fears that he will pass out if he gets to close to one.

He will not travel abroad because of his fear of spiders – and since hearing about the Funnel web spider travelling to Australia would be the worst place on earth. This is particularly problematic, as his GF of 11 years would like him to travel with her to visit her family and hometown.

On seeing a spider on TV he feels anxious and either leaves the room or turns the channel. He immediately turns pages of newspapers when he sees pictures of spiders. Before going to see a new film at the cinema he scans reviews to see if they mention spiders and asks people that have seen the movie if it have spiders in them.

Target cognition:? What thoughts could be put to the test

Alternative perspective: what’s the alternative

Experiment: What could james do??

Result: what are you hoping james might learn??

Come up with 3 experiments, could you use a survey at any point??

Social phobias often start in adolescence and are centred around a fear of scrutiny by other people in comparatively small groups (as opposed to crowds), usually leading to avoidance of social situations. Unlike most other phobias, social phobias are equally common in men and women.

They may be discrete (i.e. restricted to eating in public, to public speaking, or to encounters with the opposite sex) or diffuse, involving almost all social situations outside the family circle.Social phobias are usually associated with low self-esteem and fear of criticism.

They may present as a complaint of blushing, hand tremor, nausea, or urgency of micturition, Avoidance is often marked, and in extreme cases may result in almost complete social isolation.

(b)the anxiety must be restricted to or predominate in particular social situations; and

(c)the phobic situation is avoided whenever possible.

:

Thoughts

Mood

Behaviour

Physical

I won’t know what to say, i will freeze, everyone will think i am so weird/stupid...Ill blush /shake everyone will know i am anxious and think I am a weakling

Tight chestHeart racing

Try to avoid talking/ avoid social occasionsRehearse what to say. Try to hide anxiety/blushing etc

Fight or flight

anxious

Key processes

Self focused attention (monitoring symptoms..)

Safety seeking eg... rehearsing what to say, hide blushing or tremors..

Perceived social danger; Patients often believe that their behaviour must fall into a narrow category to be acceptable to others.

Not coping ...

Thoughts

Mood

Behaviour

Physical

People will find me stupid or boring and notice I am anxious and blushing they will laugh at me and make remarks

Tight chestHeart racing

Rehearse what to say. monitor for signs of blushing put hair over face to hide.

Fight or flight

anxious

Target cognition: If people notice that someone cheeks are red they will laugh, point make remarks.

Alternative perspective: most people are engrossed in their own thoughts, activities etc and may notice little else. If they do notice they are unlikely to react too obviously.

Prediction: people will notice and stop ,point ,stare, whisper

Experiment: Therapist made her cheeks red and went shopping with patient, patient to observe others reactions.....

Result:????? Want to try it????

Characterised by:

Recurrent obsessive *( persistent and intrusive thoughts, images or impulses)

And/or compulsions( compelling repetitive behaviour or rituals or mental acts intended to put right or neutralise the obsession)

Most common forms of OCD

Contamination fears....

Doubt and uncertainty in which people fear that something bad will happen if they do not carefully check their behaviour or do something the right number of times or in the right way......

Thoughts which the person sees as strongly inappropriate or immoral, often associated with a fear that these thoughts imply that they might carry out some objectionable action.....

Driving /walking past children

Thoughts

Mood

Behaviour

Physical

How far away is that child?Did I bump into that child?Now that I have had that thought did i do it on purpose?I must be certain that I did not cause this child harm or else I will not be able to get on with anything

Heart racing

Phone the child’s parents to check ( reassurance)Start doubting the reassurance, phone againWhere possible avoid the school run

Fight or flight

anxious

Fear of causing harm

Inflated responsibility

Thought action fusion

Intolerance of uncertainty

Jane fears that she will contaminate herself and her family with germs and has a catastrophic prediction that a family member will be physically harmed as a result of this contamination. She responds to this fear by washing her hands constantly with bleach and engages in elaborate cleaning rituals

Behavioural experiment, survey??? What do you need to take into consideration

what potential obstacles might exist?

A cognitive strategy which could be used in this instance is the survey. Jane could make a checklist to ask her friends what precautions they take to avoid contamination with germs. She could also ask how often their family members get sick.

What would you hope that Jane would discover through this?

Think about one of your own fears and consider to what extent they are maintained by the way you think about them and behave in relation to them.

What behavioural experiments could you carry out to test this out?

Could this approach to recognising and working with anxiety benefit your nursing practice ? Which aspects , where?? what would make it difficult??

David M. Clark Anxiety disorders: why they persist and how to treat them.Behaviour Research and Therapy 37 (1999) S5-S27

Clark, D. (1989) Anxiety states in Hawton et.al (eds) (1989) Cognitive Behaviour Therapy for Psychiatric Problems,Oxford medical, Oxford.

Wells, A. (1997) Cognitive Therapy of Anxiety Disorders, John Wiley and Sons, Chichester.