CBT Based CBT Based Anxiety Anxiety

ManagementManagementDr Farooq Naeem

Cognitive Behaviour Cognitive Behaviour TherapyTherapy

Behaviour therapyBehaviour therapy

Classical conditioning Classical conditioning

operant conditioningoperant conditioning Cognitive therapyCognitive therapy

emotions are due to our perception emotions are due to our perception of events of events

emotional problems due to faulty emotional problems due to faulty thinkingthinking

Does not focus very much on the pastDoes not focus very much on the past Therapist and client are equal Therapist and client are equal Effective inEffective in

DepressionDepression

Anxiety Disorders Panic Phobias Anxiety Disorders Panic Phobias

SchizophreniaSchizophrenia

And many other psychiatric problemsAnd many other psychiatric problems

BasicsBasics Link between thoughts emotions Link between thoughts emotions

amp behaviour amp behaviour Automatic thoughts Automatic thoughts Cognitive errors Cognitive errors Cognitive triad Cognitive triad beliefs about self others and the beliefs about self others and the

worldworld assumptions and beliefs assumptions and beliefs

Antecedents

Cognitions

Emotions Behaviours

Physical symptoms

Thinking distortions (negative Thinking distortions (negative automatic thoughts)automatic thoughts) Jumping to conclusionsJumping to conclusions Selective abstractionSelective abstraction OvergeneralisationOvergeneralisation Magnification or minimisationMagnification or minimisation PersonalisationPersonalisation All or nothing thinking All or nothing thinking

Important considerationsImportant considerations

FormatFormatGroupGroup

IndividualIndividual

Family involvement Family involvement Itrsquos a self help therapyItrsquos a self help therapy Therapist issuesTherapist issues Patient issuesPatient issues

Versions Versions 11

ManualisedManualised

Formulation based Formulation based 22

Cognitive behaviour therapyCognitive behaviour therapy

CBT based treatmentCBT based treatment

Self help Self help

Anxiety Anxiety

Prevalence Prevalence

6 throughout the world6 throughout the world higher in Pakistan higher in Pakistan

no study on prevalence in general no study on prevalence in general population population

Women 57 (74 non-working 36 Women 57 (74 non-working 36 working women)working women)

General hospital (GAD 56 General hospital (GAD 56 depression depression 24 and panic disorders 20) 24 and panic disorders 20)

Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles

85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60

Co morbidity Co morbidity Depression Depression

Schizophrenia Schizophrenia

Personality disrodersPersonality disroders

Organic disorders Organic disorders

Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression

What is anxietyWhat is anxiety

Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety

Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders

generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)

panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)

post traumatic stress disorderpost traumatic stress disorder

obsessive compulsive disorderobsessive compulsive disorder

specific phobia (eg of spiders)specific phobia (eg of spiders)

social phobia (social anxiety disorder)social phobia (social anxiety disorder)

acute stress disorderacute stress disorder

Situational anxiety Situational anxiety

Stress factorsStress factors

ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder

A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or

accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or

dehydration)dehydration)

Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg

churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-

headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization

(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out

(12) Fear of dying(12) Fear of dying

General symptomsGeneral symptoms

(13) Hot flushes or cold chills(13) Hot flushes or cold chills

(14) Numbness or tingling sensations(14) Numbness or tingling sensations

Symptoms of tensionSymptoms of tension

(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains

(16) Restlessness and inability to relax(16) Restlessness and inability to relax

(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension

(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing

Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or

being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going

blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of

worrying worrying

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Cognitive Behaviour Cognitive Behaviour TherapyTherapy

Behaviour therapyBehaviour therapy

Classical conditioning Classical conditioning

operant conditioningoperant conditioning Cognitive therapyCognitive therapy

emotions are due to our perception emotions are due to our perception of events of events

emotional problems due to faulty emotional problems due to faulty thinkingthinking

Does not focus very much on the pastDoes not focus very much on the past Therapist and client are equal Therapist and client are equal Effective inEffective in

DepressionDepression

Anxiety Disorders Panic Phobias Anxiety Disorders Panic Phobias

SchizophreniaSchizophrenia

And many other psychiatric problemsAnd many other psychiatric problems

BasicsBasics Link between thoughts emotions Link between thoughts emotions

amp behaviour amp behaviour Automatic thoughts Automatic thoughts Cognitive errors Cognitive errors Cognitive triad Cognitive triad beliefs about self others and the beliefs about self others and the

worldworld assumptions and beliefs assumptions and beliefs

Antecedents

Cognitions

Emotions Behaviours

Physical symptoms

Thinking distortions (negative Thinking distortions (negative automatic thoughts)automatic thoughts) Jumping to conclusionsJumping to conclusions Selective abstractionSelective abstraction OvergeneralisationOvergeneralisation Magnification or minimisationMagnification or minimisation PersonalisationPersonalisation All or nothing thinking All or nothing thinking

Important considerationsImportant considerations

FormatFormatGroupGroup

IndividualIndividual

Family involvement Family involvement Itrsquos a self help therapyItrsquos a self help therapy Therapist issuesTherapist issues Patient issuesPatient issues

Versions Versions 11

ManualisedManualised

Formulation based Formulation based 22

Cognitive behaviour therapyCognitive behaviour therapy

CBT based treatmentCBT based treatment

Self help Self help

Anxiety Anxiety

Prevalence Prevalence

6 throughout the world6 throughout the world higher in Pakistan higher in Pakistan

no study on prevalence in general no study on prevalence in general population population

Women 57 (74 non-working 36 Women 57 (74 non-working 36 working women)working women)

General hospital (GAD 56 General hospital (GAD 56 depression depression 24 and panic disorders 20) 24 and panic disorders 20)

Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles

85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60

Co morbidity Co morbidity Depression Depression

Schizophrenia Schizophrenia

Personality disrodersPersonality disroders

Organic disorders Organic disorders

Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression

What is anxietyWhat is anxiety

Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety

Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders

generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)

panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)

post traumatic stress disorderpost traumatic stress disorder

obsessive compulsive disorderobsessive compulsive disorder

specific phobia (eg of spiders)specific phobia (eg of spiders)

social phobia (social anxiety disorder)social phobia (social anxiety disorder)

acute stress disorderacute stress disorder

Situational anxiety Situational anxiety

Stress factorsStress factors

ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder

A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or

accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or

dehydration)dehydration)

Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg

churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-

headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization

(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out

(12) Fear of dying(12) Fear of dying

General symptomsGeneral symptoms

(13) Hot flushes or cold chills(13) Hot flushes or cold chills

(14) Numbness or tingling sensations(14) Numbness or tingling sensations

Symptoms of tensionSymptoms of tension

(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains

(16) Restlessness and inability to relax(16) Restlessness and inability to relax

(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension

(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing

Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or

being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going

blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of

worrying worrying

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Does not focus very much on the pastDoes not focus very much on the past Therapist and client are equal Therapist and client are equal Effective inEffective in

DepressionDepression

Anxiety Disorders Panic Phobias Anxiety Disorders Panic Phobias

SchizophreniaSchizophrenia

And many other psychiatric problemsAnd many other psychiatric problems

BasicsBasics Link between thoughts emotions Link between thoughts emotions

amp behaviour amp behaviour Automatic thoughts Automatic thoughts Cognitive errors Cognitive errors Cognitive triad Cognitive triad beliefs about self others and the beliefs about self others and the

worldworld assumptions and beliefs assumptions and beliefs

Antecedents

Cognitions

Emotions Behaviours

Physical symptoms

Thinking distortions (negative Thinking distortions (negative automatic thoughts)automatic thoughts) Jumping to conclusionsJumping to conclusions Selective abstractionSelective abstraction OvergeneralisationOvergeneralisation Magnification or minimisationMagnification or minimisation PersonalisationPersonalisation All or nothing thinking All or nothing thinking

Important considerationsImportant considerations

FormatFormatGroupGroup

IndividualIndividual

Family involvement Family involvement Itrsquos a self help therapyItrsquos a self help therapy Therapist issuesTherapist issues Patient issuesPatient issues

Versions Versions 11

ManualisedManualised

Formulation based Formulation based 22

Cognitive behaviour therapyCognitive behaviour therapy

CBT based treatmentCBT based treatment

Self help Self help

Anxiety Anxiety

Prevalence Prevalence

6 throughout the world6 throughout the world higher in Pakistan higher in Pakistan

no study on prevalence in general no study on prevalence in general population population

Women 57 (74 non-working 36 Women 57 (74 non-working 36 working women)working women)

General hospital (GAD 56 General hospital (GAD 56 depression depression 24 and panic disorders 20) 24 and panic disorders 20)

Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles

85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60

Co morbidity Co morbidity Depression Depression

Schizophrenia Schizophrenia

Personality disrodersPersonality disroders

Organic disorders Organic disorders

Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression

What is anxietyWhat is anxiety

Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety

Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders

generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)

panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)

post traumatic stress disorderpost traumatic stress disorder

obsessive compulsive disorderobsessive compulsive disorder

specific phobia (eg of spiders)specific phobia (eg of spiders)

social phobia (social anxiety disorder)social phobia (social anxiety disorder)

acute stress disorderacute stress disorder

Situational anxiety Situational anxiety

Stress factorsStress factors

ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder

A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or

accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or

dehydration)dehydration)

Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg

churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-

headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization

(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out

(12) Fear of dying(12) Fear of dying

General symptomsGeneral symptoms

(13) Hot flushes or cold chills(13) Hot flushes or cold chills

(14) Numbness or tingling sensations(14) Numbness or tingling sensations

Symptoms of tensionSymptoms of tension

(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains

(16) Restlessness and inability to relax(16) Restlessness and inability to relax

(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension

(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing

Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or

being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going

blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of

worrying worrying

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

BasicsBasics Link between thoughts emotions Link between thoughts emotions

amp behaviour amp behaviour Automatic thoughts Automatic thoughts Cognitive errors Cognitive errors Cognitive triad Cognitive triad beliefs about self others and the beliefs about self others and the

worldworld assumptions and beliefs assumptions and beliefs

Antecedents

Cognitions

Emotions Behaviours

Physical symptoms

Thinking distortions (negative Thinking distortions (negative automatic thoughts)automatic thoughts) Jumping to conclusionsJumping to conclusions Selective abstractionSelective abstraction OvergeneralisationOvergeneralisation Magnification or minimisationMagnification or minimisation PersonalisationPersonalisation All or nothing thinking All or nothing thinking

Important considerationsImportant considerations

FormatFormatGroupGroup

IndividualIndividual

Family involvement Family involvement Itrsquos a self help therapyItrsquos a self help therapy Therapist issuesTherapist issues Patient issuesPatient issues

Versions Versions 11

ManualisedManualised

Formulation based Formulation based 22

Cognitive behaviour therapyCognitive behaviour therapy

CBT based treatmentCBT based treatment

Self help Self help

Anxiety Anxiety

Prevalence Prevalence

6 throughout the world6 throughout the world higher in Pakistan higher in Pakistan

no study on prevalence in general no study on prevalence in general population population

Women 57 (74 non-working 36 Women 57 (74 non-working 36 working women)working women)

General hospital (GAD 56 General hospital (GAD 56 depression depression 24 and panic disorders 20) 24 and panic disorders 20)

Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles

85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60

Co morbidity Co morbidity Depression Depression

Schizophrenia Schizophrenia

Personality disrodersPersonality disroders

Organic disorders Organic disorders

Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression

What is anxietyWhat is anxiety

Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety

Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders

generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)

panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)

post traumatic stress disorderpost traumatic stress disorder

obsessive compulsive disorderobsessive compulsive disorder

specific phobia (eg of spiders)specific phobia (eg of spiders)

social phobia (social anxiety disorder)social phobia (social anxiety disorder)

acute stress disorderacute stress disorder

Situational anxiety Situational anxiety

Stress factorsStress factors

ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder

A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or

accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or

dehydration)dehydration)

Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg

churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-

headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization

(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out

(12) Fear of dying(12) Fear of dying

General symptomsGeneral symptoms

(13) Hot flushes or cold chills(13) Hot flushes or cold chills

(14) Numbness or tingling sensations(14) Numbness or tingling sensations

Symptoms of tensionSymptoms of tension

(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains

(16) Restlessness and inability to relax(16) Restlessness and inability to relax

(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension

(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing

Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or

being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going

blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of

worrying worrying

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Antecedents

Cognitions

Emotions Behaviours

Physical symptoms

Thinking distortions (negative Thinking distortions (negative automatic thoughts)automatic thoughts) Jumping to conclusionsJumping to conclusions Selective abstractionSelective abstraction OvergeneralisationOvergeneralisation Magnification or minimisationMagnification or minimisation PersonalisationPersonalisation All or nothing thinking All or nothing thinking

Important considerationsImportant considerations

FormatFormatGroupGroup

IndividualIndividual

Family involvement Family involvement Itrsquos a self help therapyItrsquos a self help therapy Therapist issuesTherapist issues Patient issuesPatient issues

Versions Versions 11

ManualisedManualised

Formulation based Formulation based 22

Cognitive behaviour therapyCognitive behaviour therapy

CBT based treatmentCBT based treatment

Self help Self help

Anxiety Anxiety

Prevalence Prevalence

6 throughout the world6 throughout the world higher in Pakistan higher in Pakistan

no study on prevalence in general no study on prevalence in general population population

Women 57 (74 non-working 36 Women 57 (74 non-working 36 working women)working women)

General hospital (GAD 56 General hospital (GAD 56 depression depression 24 and panic disorders 20) 24 and panic disorders 20)

Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles

85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60

Co morbidity Co morbidity Depression Depression

Schizophrenia Schizophrenia

Personality disrodersPersonality disroders

Organic disorders Organic disorders

Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression

What is anxietyWhat is anxiety

Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety

Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders

generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)

panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)

post traumatic stress disorderpost traumatic stress disorder

obsessive compulsive disorderobsessive compulsive disorder

specific phobia (eg of spiders)specific phobia (eg of spiders)

social phobia (social anxiety disorder)social phobia (social anxiety disorder)

acute stress disorderacute stress disorder

Situational anxiety Situational anxiety

Stress factorsStress factors

ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder

A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or

accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or

dehydration)dehydration)

Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg

churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-

headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization

(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out

(12) Fear of dying(12) Fear of dying

General symptomsGeneral symptoms

(13) Hot flushes or cold chills(13) Hot flushes or cold chills

(14) Numbness or tingling sensations(14) Numbness or tingling sensations

Symptoms of tensionSymptoms of tension

(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains

(16) Restlessness and inability to relax(16) Restlessness and inability to relax

(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension

(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing

Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or

being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going

blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of

worrying worrying

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Thinking distortions (negative Thinking distortions (negative automatic thoughts)automatic thoughts) Jumping to conclusionsJumping to conclusions Selective abstractionSelective abstraction OvergeneralisationOvergeneralisation Magnification or minimisationMagnification or minimisation PersonalisationPersonalisation All or nothing thinking All or nothing thinking

Important considerationsImportant considerations

FormatFormatGroupGroup

IndividualIndividual

Family involvement Family involvement Itrsquos a self help therapyItrsquos a self help therapy Therapist issuesTherapist issues Patient issuesPatient issues

Versions Versions 11

ManualisedManualised

Formulation based Formulation based 22

Cognitive behaviour therapyCognitive behaviour therapy

CBT based treatmentCBT based treatment

Self help Self help

Anxiety Anxiety

Prevalence Prevalence

6 throughout the world6 throughout the world higher in Pakistan higher in Pakistan

no study on prevalence in general no study on prevalence in general population population

Women 57 (74 non-working 36 Women 57 (74 non-working 36 working women)working women)

General hospital (GAD 56 General hospital (GAD 56 depression depression 24 and panic disorders 20) 24 and panic disorders 20)

Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles

85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60

Co morbidity Co morbidity Depression Depression

Schizophrenia Schizophrenia

Personality disrodersPersonality disroders

Organic disorders Organic disorders

Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression

What is anxietyWhat is anxiety

Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety

Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders

generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)

panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)

post traumatic stress disorderpost traumatic stress disorder

obsessive compulsive disorderobsessive compulsive disorder

specific phobia (eg of spiders)specific phobia (eg of spiders)

social phobia (social anxiety disorder)social phobia (social anxiety disorder)

acute stress disorderacute stress disorder

Situational anxiety Situational anxiety

Stress factorsStress factors

ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder

A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or

accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or

dehydration)dehydration)

Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg

churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-

headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization

(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out

(12) Fear of dying(12) Fear of dying

General symptomsGeneral symptoms

(13) Hot flushes or cold chills(13) Hot flushes or cold chills

(14) Numbness or tingling sensations(14) Numbness or tingling sensations

Symptoms of tensionSymptoms of tension

(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains

(16) Restlessness and inability to relax(16) Restlessness and inability to relax

(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension

(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing

Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or

being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going

blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of

worrying worrying

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Important considerationsImportant considerations

FormatFormatGroupGroup

IndividualIndividual

Family involvement Family involvement Itrsquos a self help therapyItrsquos a self help therapy Therapist issuesTherapist issues Patient issuesPatient issues

Versions Versions 11

ManualisedManualised

Formulation based Formulation based 22

Cognitive behaviour therapyCognitive behaviour therapy

CBT based treatmentCBT based treatment

Self help Self help

Anxiety Anxiety

Prevalence Prevalence

6 throughout the world6 throughout the world higher in Pakistan higher in Pakistan

no study on prevalence in general no study on prevalence in general population population

Women 57 (74 non-working 36 Women 57 (74 non-working 36 working women)working women)

General hospital (GAD 56 General hospital (GAD 56 depression depression 24 and panic disorders 20) 24 and panic disorders 20)

Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles

85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60

Co morbidity Co morbidity Depression Depression

Schizophrenia Schizophrenia

Personality disrodersPersonality disroders

Organic disorders Organic disorders

Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression

What is anxietyWhat is anxiety

Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety

Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders

generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)

panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)

post traumatic stress disorderpost traumatic stress disorder

obsessive compulsive disorderobsessive compulsive disorder

specific phobia (eg of spiders)specific phobia (eg of spiders)

social phobia (social anxiety disorder)social phobia (social anxiety disorder)

acute stress disorderacute stress disorder

Situational anxiety Situational anxiety

Stress factorsStress factors

ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder

A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or

accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or

dehydration)dehydration)

Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg

churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-

headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization

(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out

(12) Fear of dying(12) Fear of dying

General symptomsGeneral symptoms

(13) Hot flushes or cold chills(13) Hot flushes or cold chills

(14) Numbness or tingling sensations(14) Numbness or tingling sensations

Symptoms of tensionSymptoms of tension

(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains

(16) Restlessness and inability to relax(16) Restlessness and inability to relax

(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension

(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing

Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or

being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going

blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of

worrying worrying

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Versions Versions 11

ManualisedManualised

Formulation based Formulation based 22

Cognitive behaviour therapyCognitive behaviour therapy

CBT based treatmentCBT based treatment

Self help Self help

Anxiety Anxiety

Prevalence Prevalence

6 throughout the world6 throughout the world higher in Pakistan higher in Pakistan

no study on prevalence in general no study on prevalence in general population population

Women 57 (74 non-working 36 Women 57 (74 non-working 36 working women)working women)

General hospital (GAD 56 General hospital (GAD 56 depression depression 24 and panic disorders 20) 24 and panic disorders 20)

Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles

85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60

Co morbidity Co morbidity Depression Depression

Schizophrenia Schizophrenia

Personality disrodersPersonality disroders

Organic disorders Organic disorders

Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression

What is anxietyWhat is anxiety

Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety

Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders

generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)

panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)

post traumatic stress disorderpost traumatic stress disorder

obsessive compulsive disorderobsessive compulsive disorder

specific phobia (eg of spiders)specific phobia (eg of spiders)

social phobia (social anxiety disorder)social phobia (social anxiety disorder)

acute stress disorderacute stress disorder

Situational anxiety Situational anxiety

Stress factorsStress factors

ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder

A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or

accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or

dehydration)dehydration)

Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg

churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-

headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization

(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out

(12) Fear of dying(12) Fear of dying

General symptomsGeneral symptoms

(13) Hot flushes or cold chills(13) Hot flushes or cold chills

(14) Numbness or tingling sensations(14) Numbness or tingling sensations

Symptoms of tensionSymptoms of tension

(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains

(16) Restlessness and inability to relax(16) Restlessness and inability to relax

(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension

(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing

Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or

being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going

blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of

worrying worrying

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Anxiety Anxiety

Prevalence Prevalence

6 throughout the world6 throughout the world higher in Pakistan higher in Pakistan

no study on prevalence in general no study on prevalence in general population population

Women 57 (74 non-working 36 Women 57 (74 non-working 36 working women)working women)

General hospital (GAD 56 General hospital (GAD 56 depression depression 24 and panic disorders 20) 24 and panic disorders 20)

Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles

85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60

Co morbidity Co morbidity Depression Depression

Schizophrenia Schizophrenia

Personality disrodersPersonality disroders

Organic disorders Organic disorders

Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression

What is anxietyWhat is anxiety

Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety

Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders

generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)

panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)

post traumatic stress disorderpost traumatic stress disorder

obsessive compulsive disorderobsessive compulsive disorder

specific phobia (eg of spiders)specific phobia (eg of spiders)

social phobia (social anxiety disorder)social phobia (social anxiety disorder)

acute stress disorderacute stress disorder

Situational anxiety Situational anxiety

Stress factorsStress factors

ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder

A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or

accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or

dehydration)dehydration)

Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg

churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-

headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization

(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out

(12) Fear of dying(12) Fear of dying

General symptomsGeneral symptoms

(13) Hot flushes or cold chills(13) Hot flushes or cold chills

(14) Numbness or tingling sensations(14) Numbness or tingling sensations

Symptoms of tensionSymptoms of tension

(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains

(16) Restlessness and inability to relax(16) Restlessness and inability to relax

(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension

(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing

Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or

being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going

blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of

worrying worrying

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Somatic complaints Somatic complaints generalized headache 70 generalized headache 70 pain neck and upper trunk muscles pain neck and upper trunk muscles

85 85 backache 52 backache 52 palpitation 45 palpitation 45 chest pain 25 chest pain 25 dyspepsia 60 dyspepsia 60

Co morbidity Co morbidity Depression Depression

Schizophrenia Schizophrenia

Personality disrodersPersonality disroders

Organic disorders Organic disorders

Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression

What is anxietyWhat is anxiety

Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety

Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders

generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)

panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)

post traumatic stress disorderpost traumatic stress disorder

obsessive compulsive disorderobsessive compulsive disorder

specific phobia (eg of spiders)specific phobia (eg of spiders)

social phobia (social anxiety disorder)social phobia (social anxiety disorder)

acute stress disorderacute stress disorder

Situational anxiety Situational anxiety

Stress factorsStress factors

ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder

A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or

accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or

dehydration)dehydration)

Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg

churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-

headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization

(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out

(12) Fear of dying(12) Fear of dying

General symptomsGeneral symptoms

(13) Hot flushes or cold chills(13) Hot flushes or cold chills

(14) Numbness or tingling sensations(14) Numbness or tingling sensations

Symptoms of tensionSymptoms of tension

(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains

(16) Restlessness and inability to relax(16) Restlessness and inability to relax

(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension

(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing

Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or

being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going

blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of

worrying worrying

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Co morbidity Co morbidity Depression Depression

Schizophrenia Schizophrenia

Personality disrodersPersonality disroders

Organic disorders Organic disorders

Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression

What is anxietyWhat is anxiety

Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety

Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders

generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)

panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)

post traumatic stress disorderpost traumatic stress disorder

obsessive compulsive disorderobsessive compulsive disorder

specific phobia (eg of spiders)specific phobia (eg of spiders)

social phobia (social anxiety disorder)social phobia (social anxiety disorder)

acute stress disorderacute stress disorder

Situational anxiety Situational anxiety

Stress factorsStress factors

ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder

A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or

accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or

dehydration)dehydration)

Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg

churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-

headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization

(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out

(12) Fear of dying(12) Fear of dying

General symptomsGeneral symptoms

(13) Hot flushes or cold chills(13) Hot flushes or cold chills

(14) Numbness or tingling sensations(14) Numbness or tingling sensations

Symptoms of tensionSymptoms of tension

(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains

(16) Restlessness and inability to relax(16) Restlessness and inability to relax

(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension

(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing

Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or

being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going

blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of

worrying worrying

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Nearly 70 of patients in Nearly 70 of patients in outpatient clinics in Pakistan present outpatient clinics in Pakistan present with a mixture of anxiety and with a mixture of anxiety and depression depression

What is anxietyWhat is anxiety

Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety

Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders

generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)

panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)

post traumatic stress disorderpost traumatic stress disorder

obsessive compulsive disorderobsessive compulsive disorder

specific phobia (eg of spiders)specific phobia (eg of spiders)

social phobia (social anxiety disorder)social phobia (social anxiety disorder)

acute stress disorderacute stress disorder

Situational anxiety Situational anxiety

Stress factorsStress factors

ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder

A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or

accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or

dehydration)dehydration)

Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg

churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-

headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization

(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out

(12) Fear of dying(12) Fear of dying

General symptomsGeneral symptoms

(13) Hot flushes or cold chills(13) Hot flushes or cold chills

(14) Numbness or tingling sensations(14) Numbness or tingling sensations

Symptoms of tensionSymptoms of tension

(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains

(16) Restlessness and inability to relax(16) Restlessness and inability to relax

(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension

(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing

Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or

being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going

blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of

worrying worrying

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

What is anxietyWhat is anxiety

Types of anxiety Types of anxiety Generalised anxiety Generalised anxiety

Specific fears phobias and panic attacksSpecific fears phobias and panic attacks Anxiety disordersAnxiety disorders

generalised anxiety disorder (GAD)generalised anxiety disorder (GAD)

panic disorder (with or without panic disorder (with or without agoraphobia)agoraphobia)

post traumatic stress disorderpost traumatic stress disorder

obsessive compulsive disorderobsessive compulsive disorder

specific phobia (eg of spiders)specific phobia (eg of spiders)

social phobia (social anxiety disorder)social phobia (social anxiety disorder)

acute stress disorderacute stress disorder

Situational anxiety Situational anxiety

Stress factorsStress factors

ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder

A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or

accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or

dehydration)dehydration)

Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg

churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-

headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization

(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out

(12) Fear of dying(12) Fear of dying

General symptomsGeneral symptoms

(13) Hot flushes or cold chills(13) Hot flushes or cold chills

(14) Numbness or tingling sensations(14) Numbness or tingling sensations

Symptoms of tensionSymptoms of tension

(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains

(16) Restlessness and inability to relax(16) Restlessness and inability to relax

(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension

(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing

Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or

being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going

blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of

worrying worrying

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

post traumatic stress disorderpost traumatic stress disorder

obsessive compulsive disorderobsessive compulsive disorder

specific phobia (eg of spiders)specific phobia (eg of spiders)

social phobia (social anxiety disorder)social phobia (social anxiety disorder)

acute stress disorderacute stress disorder

Situational anxiety Situational anxiety

Stress factorsStress factors

ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder

A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or

accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or

dehydration)dehydration)

Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg

churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-

headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization

(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out

(12) Fear of dying(12) Fear of dying

General symptomsGeneral symptoms

(13) Hot flushes or cold chills(13) Hot flushes or cold chills

(14) Numbness or tingling sensations(14) Numbness or tingling sensations

Symptoms of tensionSymptoms of tension

(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains

(16) Restlessness and inability to relax(16) Restlessness and inability to relax

(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension

(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing

Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or

being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going

blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of

worrying worrying

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

ICD 10 (RampDC) F411 Generalized ICD 10 (RampDC) F411 Generalized Anxiety DisorderAnxiety Disorder

A Period of at least six months A Period of at least six months B At least four of these symptoms B At least four of these symptoms at least one from itemsat least one from items(1) to (4)(1) to (4)Autonomic arousal symptomsAutonomic arousal symptoms(1) Palpitations or pounding heart or (1) Palpitations or pounding heart or

accelerated heart rateaccelerated heart rate(2) Sweating(2) Sweating(3) Trembling or shaking(3) Trembling or shaking(4) Dry mouth (not due to medication or (4) Dry mouth (not due to medication or

dehydration)dehydration)

Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg

churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-

headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization

(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out

(12) Fear of dying(12) Fear of dying

General symptomsGeneral symptoms

(13) Hot flushes or cold chills(13) Hot flushes or cold chills

(14) Numbness or tingling sensations(14) Numbness or tingling sensations

Symptoms of tensionSymptoms of tension

(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains

(16) Restlessness and inability to relax(16) Restlessness and inability to relax

(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension

(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing

Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or

being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going

blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of

worrying worrying

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Symptoms concerning chest and abdomenSymptoms concerning chest and abdomen(5) Difficulty breathing(5) Difficulty breathing(6) Feeling of choking(6) Feeling of choking(7) Chest pain or discomfort(7) Chest pain or discomfort(8) Nausea or abdominal distress (eg (8) Nausea or abdominal distress (eg

churning in stomach)churning in stomach)Symptoms concerning brain and mindSymptoms concerning brain and mind(9) Feeling dizzy unsteady faint or light-(9) Feeling dizzy unsteady faint or light-

headedheaded(10) Derealization or depersonalization(10) Derealization or depersonalization

(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out

(12) Fear of dying(12) Fear of dying

General symptomsGeneral symptoms

(13) Hot flushes or cold chills(13) Hot flushes or cold chills

(14) Numbness or tingling sensations(14) Numbness or tingling sensations

Symptoms of tensionSymptoms of tension

(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains

(16) Restlessness and inability to relax(16) Restlessness and inability to relax

(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension

(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing

Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or

being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going

blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of

worrying worrying

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

(11) Fear of losing control going crazy or (11) Fear of losing control going crazy or passing outpassing out

(12) Fear of dying(12) Fear of dying

General symptomsGeneral symptoms

(13) Hot flushes or cold chills(13) Hot flushes or cold chills

(14) Numbness or tingling sensations(14) Numbness or tingling sensations

Symptoms of tensionSymptoms of tension

(15) Muscle tension or aches and pains(15) Muscle tension or aches and pains

(16) Restlessness and inability to relax(16) Restlessness and inability to relax

(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension

(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing

Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or

being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going

blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of

worrying worrying

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

(17) Feeling keyed up or on edge or of mental (17) Feeling keyed up or on edge or of mental tensiontension

(18) A sensation of a lump in the throat or (18) A sensation of a lump in the throat or difficulty with swallowingdifficulty with swallowing

Other non-specific symptomsOther non-specific symptoms(19) Exaggerated response to minor surprises or (19) Exaggerated response to minor surprises or

being startledbeing startled(20) Difficulty in concentrating or mind going (20) Difficulty in concentrating or mind going

blank because of worrying or anxietyblank because of worrying or anxiety(21) Persistent irritability(21) Persistent irritability(22) Difficulty getting to sleep because of (22) Difficulty getting to sleep because of

worrying worrying

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

C The disorder does not meet the criteria for panic C The disorder does not meet the criteria for panic disorder (F410) phobic anxiety disorders (F40-)disorder (F410) phobic anxiety disorders (F40-)

obsessive-compulsive disorder (F42-) or obsessive-compulsive disorder (F42-) or hypochondriacal disorder (F452)hypochondriacal disorder (F452)

D Most commonly used exclusion criteria not D Most commonly used exclusion criteria not sustained by a physical disorder such as sustained by a physical disorder such as hyperthyroidism anhyperthyroidism an

organic mental disorder (F0) or psychoactive organic mental disorder (F0) or psychoactive substance-related disorder (F1) such as excess substance-related disorder (F1) such as excess consumptionconsumption

of amphetamine-like substances or withdrawal of amphetamine-like substances or withdrawal from benzodiazepinesfrom benzodiazepines

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

National institute of National institute of clinical excellence (NICE) clinical excellence (NICE)

UK guidelines UK guidelines Generalised anxiety disorder1 Immediate management 1048714 support and information (D)1048714 problem solving (C)1048714 benzodiazepines (A)1048714 sedating antihistamines (A)1048714 self help (D)2 Benzodiazepines not beyond 2-4

weeks (B)

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

3 Longer-term care of individuals 3 Longer-term care of individuals

Evidence based Interventions in descending Evidence based Interventions in descending orderorder

1048714 1048714 psychological therapy (A)psychological therapy (A)

1048714 1048714 pharmacological therapy (antidepressant pharmacological therapy (antidepressant medication) (A)medication) (A)

1048714 1048714 self-help (A)self-help (A)

4 The treatment option of choice should be 4 The treatment option of choice should be available promptly (D)available promptly (D)

5 positive advantages of services based in primary 5 positive advantages of services based in primary care care

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Psychological interventionsPsychological interventions

6 CBT should be used (A)6 CBT should be used (A)

7 delivered only by suitably trained 7 delivered only by suitably trained and supervised people who adhere and supervised people who adhere closely to empirically grounded closely to empirically grounded treatment protocols treatment protocols

8 optimal range of duration (16-20 8 optimal range of duration (16-20 hours) hours)

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

9 weekly sessions of 1-2 hours 9 weekly sessions of 1-2 hours completed within 4 months completed within 4 months

10 briefer CBT supplement with 10 briefer CBT supplement with appropriate focussed information appropriate focussed information and tasks (A)and tasks (A)

11 Where briefer CBT is used it 11 Where briefer CBT is used it should be around 8-10 hours and be should be around 8-10 hours and be designed to integrate with designed to integrate with structured self-help materials structured self-help materials

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Pharmacological interventionsPharmacological interventions12 The following must be taken into account12 The following must be taken into account1048714 1048714 the age of the patient (D)the age of the patient (D)1048714 1048714 previous treatment response (D)previous treatment response (D)1048714 1048714 risksrisks1048714 1048714 the likelihood of accidental overdose the likelihood of accidental overdose 1048714 1048714 the likelihood of deliberate self harmthe likelihood of deliberate self harm tolerability (D)tolerability (D)1048714 1048714 the preference of the person being treated the preference of the person being treated

(D)(D)1048714 1048714 cost where equal effectiveness is cost where equal effectiveness is

demonstrated demonstrated

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

15 An SSRI should be offered (B)15 An SSRI should be offered (B)

16 If no improvement after 12-week course 16 If no improvement after 12-week course another SSRI another SSRI

17 Consider the following17 Consider the following

1048714 1048714 start at a low dose and increasing the dose slowly start at a low dose and increasing the dose slowly

1048714 1048714 In some instances high doses might be needed In some instances high doses might be needed (B)(B)

1048714 1048714 Long-term treatment may be necessary for some Long-term treatment may be necessary for some

1048714 1048714 If the patient is showing improvement continue If the patient is showing improvement continue for at least 6 months after the optimal dose is for at least 6 months after the optimal dose is reachedreached

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Self-help interventionsSelf-help interventions

25 Bibliotherapy based on CBT principles 25 Bibliotherapy based on CBT principles (A)(A)

26 Information about support groups if 26 Information about support groups if available available

27 Large group CBT should be considered 27 Large group CBT should be considered (C)(C)

28 The benefits of exercise be discussed (B)28 The benefits of exercise be discussed (B)

29 CBT via a computer interface (CCBT) 29 CBT via a computer interface (CCBT)

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

RecommendationsRecommendations

1 CBT should be used (A)1 CBT should be used (A)

2 2 CBT has been found to maintain its CBT has been found to maintain its effectiveness when examined after long term effectiveness when examined after long term follow up (8-14 years) (Ib)follow up (8-14 years) (Ib)

3 Most patients at longer term follow up 3 Most patients at longer term follow up maintained treatment gainsmaintained treatment gains

4 In large group settings CBT more effective 4 In large group settings CBT more effective than attention placebo both in the short and than attention placebo both in the short and long term (Ib)long term (Ib)

5 CBT is effective for GAD in older people (Ib)5 CBT is effective for GAD in older people (Ib)

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

6 6 more effective than psycho dynamic more effective than psycho dynamic therapy and non-specific treatments (Ia)therapy and non-specific treatments (Ia)

7 more contact with therapist (16-20 7 more contact with therapist (16-20 sessions) did not result in better sessions) did not result in better outcomes than less contact (8-10 outcomes than less contact (8-10 sessions) (Ib)sessions) (Ib)

8 Anxiety management training 8 Anxiety management training relaxation and breathing therapy are relaxation and breathing therapy are more effective than no intervention (Ia)more effective than no intervention (Ia)

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Research evidence (summary)Research evidence (summary)

Cognitive and behavioural techniques Cognitive and behavioural techniques combined had greater effect sizes than the combined had greater effect sizes than the individual interventions (Ia)individual interventions (Ia)

2 In the short term cognitive and 2 In the short term cognitive and behavioural techniques were as effective behavioural techniques were as effective as pharmacological therapies but evidence as pharmacological therapies but evidence is lacking for long term effectiveness (Ia)is lacking for long term effectiveness (Ia)

3 no difference in treatment outcomes for 3 no difference in treatment outcomes for men and womenmen and women

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

CBT in Pak Intial CBT in Pak Intial findingsfindings

Findings from Qualitative studyFindings from Qualitative study Interview with 7 psychologistsInterview with 7 psychologists Therapists Therapists

REBT backgroundREBT background Diagnosesproblems Diagnosesproblems

Anxiety disorders and depression (60-Anxiety disorders and depression (60-70)70)

Family conflicts bereavement otherFamily conflicts bereavement other

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Logistics Logistics Number per day (3-8) Number per day (3-8) Referrals (psychiatrists )Referrals (psychiatrists ) Follow up (lt30)Follow up (lt30) Number of planned sessions upto 12 Number of planned sessions upto 12 Gap between sessions 1 to 4 weeksGap between sessions 1 to 4 weeks Always along with medical treatmentAlways along with medical treatment

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Presenting complaintsPresenting complaintsMainly somatic somaticMainly somatic somatic

Poor follow up Poor follow up Distance and moneyDistance and money

Female genderFemale gender

Low social status and lack of education Low social status and lack of education

Pills oriented and not psychological Pills oriented and not psychological mindedminded

What about role of faith healersWhat about role of faith healers

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Psychiatrists donrsquot refer properlyPsychiatrists donrsquot refer properlyPsychiatrists donrsquot know much about Psychiatrists donrsquot know much about

therapytherapyPatients donrsquot come back when they are Patients donrsquot come back when they are

symptoms freesymptoms free Process of therapy Process of therapy

Assessment Assessment family involvementfamily involvementList of strengths and difficulties List of strengths and difficulties List of presenting complaints List of presenting complaints Psychometric tests Psychometric tests

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Therapy ingredients Therapy ingredients Supportive therapySupportive therapy

Psycho educationPsycho education

PsychotherapyPsychotherapy

Family workFamily work Common techniquesCommon techniques

cognitive errors teachingcognitive errors teaching

cognitive restructuring cognitive restructuring

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Problem solvingProblem solving

Social skillsSocial skills

Assertiveness trainingAssertiveness training

Monitoring moodMonitoring mood

Communication skillsCommunication skills

Work on irrational beliefsWork on irrational beliefs

Behavioural methodsBehavioural methods

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Hurdles in therapyHurdles in therapy homeworkhomework Problems will be solved in 1Problems will be solved in 1stst session session personal satisfactionpersonal satisfaction therapists factorstherapists factors explaining cognitive errors explaining cognitive errors (translation)(translation) negative thoughts (people donrsquot like it)negative thoughts (people donrsquot like it) family involved too muchfamily involved too much Involvement of non medical healersInvolvement of non medical healers

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Overcoming hurdlesOvercoming hurdlesTake into consideration hurdlesTake into consideration hurdles

Coping statements (amp prompt cards)Coping statements (amp prompt cards)

Biblio therapyBiblio therapy

Cultural context Cultural context

patients think its gupshup patients think its gupshup One single message from each session One single message from each session

Use of imagery Use of imagery

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Repeat shorter gapsRepeat shorter gaps

RapportRapport

Use of tapes written materialUse of tapes written material Style of therapyStyle of therapy

instructional not collaborativeinstructional not collaborative

authoritative not authoritarianauthoritative not authoritarian

giving direct advice or giving direct advice or Socratic Socratic dialoguedialogue

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Causes of anxiety disordersCauses of anxiety disorders

Long term predisposing causesLong term predisposing causes heredityheredity childhood circumstanceschildhood circumstances

overprotective parentsoverprotective parents

over critical parentsover critical parents

emotional insecurity and dependenceemotional insecurity and dependence

controlling parents controlling parents

parents who make child feel guilty or parents who make child feel guilty or ashamedashamed

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

parental neglect (emotional)parental neglect (emotional)

parental abuse parental abuse

cumulative stress over timecumulative stress over time

childhood abuse (physical sexual or childhood abuse (physical sexual or emotional)emotional)

other illnesses insecuritiesother illnesses insecurities

other problems which cause low self other problems which cause low self esteemesteem

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Biological causesBiological causesphysiological disease chronic illnessphysiological disease chronic illness

drug or alcohol abuse drug or alcohol abuse

psychological causespsychological causes

stress ongoing or acutestress ongoing or acute

trauma trauma

personalitypersonality

another psychiatric conditionanother psychiatric condition

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

underlying beliefsunderlying beliefs

ongoing stressesongoing stresses

lack of assertivenesslack of assertiveness

lack of self nurturing skillslack of self nurturing skills

muscle tension or other bodily muscle tension or other bodily symptomssymptoms

stimulants and dietry factorsstimulants and dietry factors

high stress lifestylehigh stress lifestyle

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

lack of meaning or purpose in lifelack of meaning or purpose in lifeworking without breaksworking without breakswithheld feelings withheld feelings

Drugs and Medical conditions that Drugs and Medical conditions that cause anxiety or paniccause anxiety or panicHyperventilationHyperventilationHypoglycaemiaHypoglycaemiaHyperthyroidismHyperthyroidismMitral valave prolapseMitral valave prolapse

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Precipitating (triggering) causesPrecipitating (triggering) causesany significant stress or life event (- or +)any significant stress or life event (- or +)personal losspersonal losslife changeslife changesdrugs (pharmacological or recreational)drugs (pharmacological or recreational)TraumaTrauma

maintaining causesmaintaining causesavoidance of some situations (if avoidance of some situations (if

situational)situational)unhelpful thoughts (cognitive errors)unhelpful thoughts (cognitive errors)

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Premenstrual syndromePremenstrual syndromeInner ear disturbancesInner ear disturbancesChronic diseaseChronic diseaseCocaine amphetamine caffeine other Cocaine amphetamine caffeine other

stimulants stimulants Withdrwawl from alcohol sedative Withdrwawl from alcohol sedative

hypnotics or tranquilisershypnotics or tranquilisersCushing syndromeCushing syndromeParathyroidismParathyroidismComplex partial seizuresComplex partial seizures

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Post concussion syndromePost concussion syndrome

Deficiencies of calcium magnesium postassium Deficiencies of calcium magnesium postassium niacin vitamin B12niacin vitamin B12

EmphysemaEmphysema

Pulmonary embolismPulmonary embolism

Cardiac arrythmiasCardiac arrythmias

Congestive heart failureCongestive heart failure

Essential hypertensionEssential hypertension

Toxins mercury carbon dioxide food addititves Toxins mercury carbon dioxide food addititves pesticidespesticides

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Sharing your understanding with Sharing your understanding with the patient the patient

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Assessment Assessment

Demographic dataDemographic data Presenting complaints concernsPresenting complaints concerns Description of the current episode Description of the current episode Comorbid disorders Comorbid disorders Medical historyMedical history Past history Past history

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Personal history Personal history Patients perception of problem Patients perception of problem Family history Family history Social history Social history Personality assessmentPersonality assessment Coping skills Coping skills

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Principles of assessment Principles of assessment Therapeutic relationship (warmth Therapeutic relationship (warmth

empathy genuineness trust)empathy genuineness trust) Explore patients ideas about medical Explore patients ideas about medical

systemsystem cause of problems and treatmentcause of problems and treatment Prepare the patient for cognitive therapy Prepare the patient for cognitive therapy Collaboration Vs instructionsCollaboration Vs instructions Balance (not being too brief or too Balance (not being too brief or too

detailed)detailed) Body language Body language

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Reflection repetition and summarizing Reflection repetition and summarizing Questioning not answering Questioning not answering Ask for examples to get a clear pictureAsk for examples to get a clear picture Supervision and training Supervision and training Use of scales Use of scales Be natural Be natural Enjoy itEnjoy it

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Use of scalesUse of scales

Screening or diagnosticScreening or diagnostic Measurement of changeMeasurement of change hospital anxiety and depression hospital anxiety and depression beck anxiety scalebeck anxiety scale Hamilton anxiety scaleHamilton anxiety scale Pakistan anxiety and depression Pakistan anxiety and depression

scalescale Bradford somatic inventoryBradford somatic inventory

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Comprehensive Comprehensive management management

Physiological levelPhysiological levelPsycho education support Psycho education support

reduce arousal Breathing muscle reduce arousal Breathing muscle relaxationrelaxation

Emotional level Emotional level Suppressed feelingsSuppressed feelings

Learning to express your feelingsLearning to express your feelings

Communicate properly (assertiveness Communicate properly (assertiveness communication skills) communication skills)

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Behavioural level Behavioural level activity schedulingactivity scheduling

aerobic exercises aerobic exercises

eliminate avoidance behaviours eliminate avoidance behaviours

address problem behavioursaddress problem behaviours

problem solving problem solving

coping techniques coping techniques

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Mental and Psychological levelMental and Psychological levelself talk (worrying thoughts cognitive self talk (worrying thoughts cognitive

errors)errors)

dealing with cognitive errorsdealing with cognitive errors

dealing with underlying beliefsdealing with underlying beliefs

anger shame and guiltanger shame and guilt

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Interpersonal levelInterpersonal levelConflict managementConflict management

Communication skillsCommunication skills

Assertiveness Assertiveness

How to deal with an aggressive or How to deal with an aggressive or controlling personcontrolling person

Time management Time management

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

whole self levelwhole self levelLow self esteemLow self esteem

Confidence building Confidence building Spiritual and religious levelSpiritual and religious level Lifestyle and diet etc Lifestyle and diet etc Use of Medication Use of Medication

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Relaxations exercises Relaxations exercises

Rationale for relaxation exerciseRationale for relaxation exercise Role of autonomic nervous system Role of autonomic nervous system

overactivityoveractivity Use of hyperventilation to induce Use of hyperventilation to induce

anxiety or panicanxiety or panic Variety of techniquesVariety of techniques Which method or style is bestWhich method or style is best Progressive muscle relaxation Progressive muscle relaxation breathing exercise breathing exercise

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Imagery Imagery Mindfulness (body environment amp Mindfulness (body environment amp

thoughts)thoughts) Meditation Meditation Focusing on a pointFocusing on a point Repeated religious words (wird)Repeated religious words (wird) Counting breaths (allah ho) Counting breaths (allah ho)

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Breathing amp muscle Breathing amp muscle relaxation relaxation

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Principles of time Principles of time management management

PrioritizationPrioritization DelegationDelegation Allowing extra timeAllowing extra time Beware of perfectionsistic traitsBeware of perfectionsistic traits Think about ambition greed and Think about ambition greed and

overinvolvement with workoverinvolvement with work Saying noSaying no Making list of thingsMaking list of things Using a diaryUsing a diary

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Distraction techniquesDistraction techniques

Talk to someoneTalk to someone Focus on subjects in your Focus on subjects in your

surroundingssurroundings Do simple repetitive tasks (count Do simple repetitive tasks (count

wird etc)wird etc) Coping strategiesCoping strategies Engage in physical activityEngage in physical activity Do something pleasureable Do something pleasureable

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Self talkSelf talk

worrierworrieranticipating the worstanticipating the worstoverestimating the odds of bad things happeningoverestimating the odds of bad things happeningcreating grandiose images or potential of failure creating grandiose images or potential of failure

ororcatastrophecatastrophe

the criticthe criticalways judges you and your actionsalways judges you and your actionsalways draws attention to your shortcomingsalways draws attention to your shortcomingscompares with others and think of them as compares with others and think of them as

better better ignores your positive qualititesignores your positive qualitites

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

VictimVictimalways feels hopeless or helplessalways feels hopeless or helpless

always complains about things always complains about things

something wrong with you (deprived something wrong with you (deprived defective or defective or

unworthy) unworthy)

need for approval and agreement from othersneed for approval and agreement from others

dependence on others (emotional physicaldependence on others (emotional physical

psychological)psychological)

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

PerfectionistPerfectionistyour efforts are not good enoughyour efforts are not good enough

you should work even harderyou should work even harder

you should always have things under your you should always have things under your controlcontrol

people are either good or bad nothing in people are either good or bad nothing in betweenbetween

should always make people happyshould always make people happy

should always succeedshould always succeed

should always be humble should always be humble

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

How to deal with these self How to deal with these self talkstalks

What is the evidence for thisWhat is the evidence for this Is this always trueIs this always true Has this been true in the pastHas this been true in the past What are the odds of this being trueWhat are the odds of this being true What is the worst that could happenWhat is the worst that could happen Am I looking at the whole pictureAm I looking at the whole picture

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Downward arrow techniqueDownward arrow technique Socratic dialogueSocratic dialogue Identify common statements Identify common statements Prepare counterstatements Prepare counterstatements

avoid negativesavoid negativeskeep in present sensekeep in present sensekeep in first personkeep in first personthere must be some belief in statementthere must be some belief in statementsome evidence of the statementsome evidence of the statement

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Downward arrow techniqueDownward arrow technique

Socratic dialogue Socratic dialogue

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

What is your coping styleWhat is your coping style

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Coping (strategies) with Coping (strategies) with stressstress

physical strategiesphysical strategies

relaxationrelaxation

dietdiet

exerciseexercise

taking breakstaking breaks

time managemengenttime managemengent

sleep hygienssleep hygiens

environmentenvironment

material securitymaterial security

Emotional strategiesEmotional strategies

social support and social support and relatednessrelatedness

self nurturingself nurturing

assertivenessassertiveness

good communicationgood communication

assertivenessassertiveness

recreational activitiesrecreational activities

emotional releasseemotional releasse

sense of humoursense of humour

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Cognitive Cognitive strategiesstrategies

flexible constructive flexible constructive and alternative and alternative thinkingthinking

distractiondistraction

task oriented (vs task oriented (vs reactive)reactive)

Positive Self talkPositive Self talk

spiritualspiritual

acceptance and acceptance and forgivenessforgiveness

tolerance amp patience tolerance amp patience

trust in others trust in others

faith in good outcome faith in good outcome of future of future

purpose of life and purpose of life and workwork

religiousspiritual lifereligiousspiritual life

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Communication amp Communication amp conflictsconflicts

Avoid batteling with the other personAvoid batteling with the other person Agree to disagreeAgree to disagree I statement rather than vague I statement rather than vague

statementsstatements Avoid judgements Avoid judgements donrsquot jump to conclusions donrsquot jump to conclusions Refer to other persons particular Refer to other persons particular

behaviourbehaviour Avoid generalistation Avoid generalistation

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Assertiveness tipsAssertiveness tips

StylesStylesPassivePassive

AggressiveAggressive

ManipulativeManipulative

AssertiveAssertive Pakistani cultural context Pakistani cultural context religious aspects religious aspects

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

PrinciplesPrinciplesExpress your feelingsExpress your feelings

Ask for what you want (specific)Ask for what you want (specific)

Say no to something you donrsquot wantSay no to something you donrsquot want

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Tips on assertivenessTips on assertiveness

Non verbal assertive behaviourNon verbal assertive behaviour Looking directly at another personLooking directly at another person

Body language (eg crossing arms etc)Body language (eg crossing arms etc)

Donrsquot move away (donrsquot leave the room)Donrsquot move away (donrsquot leave the room)

Stay calm Stay calm Know their human rights and assert Know their human rights and assert

themthem Read on basic human rights Read on basic human rights

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Be aware of what you want (decision Be aware of what you want (decision making) making) Be clear about what you wantBe clear about what you want

Know your feelingsKnow your feelings

What you want and what you donrsquot wantWhat you want and what you donrsquot want Practice and planPractice and plan

Speicify the situation and your reponseSpeicify the situation and your reponse

Specific clear concise Specific clear concise not long vague storynot long vague story

Write or prepare a statement Write or prepare a statement

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

developing a response developing a response evaluate your rights evaluate your rights

decide on a time and placedecide on a time and place

address the main person(s) address the main person(s)

state the problems in terms of specific relation state the problems in terms of specific relation with youwith you

express your feelings (I statments)express your feelings (I statments)

suggest an alternative(s) suggest an alternative(s)

talk about specific (realistic) consequences talk about specific (realistic) consequences

start with less threatening or less authoritarian start with less threatening or less authoritarian personperson

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Practising assertion role playPractising assertion role play

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Learn to say noLearn to say no Acknowledge the other persons request by Acknowledge the other persons request by

repeating itrepeating it Explain your reason for declingingExplain your reason for declinging (in pak always keep a list of excuses)(in pak always keep a list of excuses) say nosay no suggest an alternative suggest an alternative take your time (give me some time to think take your time (give me some time to think

about it)about it) donrsquot apologize too muchdonrsquot apologize too much be speficicbe speficic assertive body languageassertive body language dealing with guilt dealing with guilt

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

role playing real liferole playing real life

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Nutrition and parhezNutrition and parhez

Foods that aggravate Foods that aggravate anxietyanxiety

Caffeine Nicotine Caffeine Nicotine alcoholalcohol

Stimulant drugsStimulant drugs High salt dietHigh salt diet chocolatechocolate PreservativesPreservatives Red meat and Red meat and

animlas fed on animlas fed on hormoneshormones

Eating habitsEating habitsEating quickly Eating quickly

(mindful eating)(mindful eating)No chewing (15-20 No chewing (15-20

mouthfuls)mouthfuls)Eating too muc Eating too muc

Drinking too much Drinking too much fluid during mealfluid during meal

Sugar and Sugar and hypoglycaemiahypoglycaemia

Food allergy Food allergy

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Good diet for reducing Good diet for reducing anxietyanxiety

Eat more vegetables Eat more vegetables and fruitsand fruits

More raw vegetables More raw vegetables Careful with what Careful with what

you eatyou eat Stop eating refined Stop eating refined

and processed foodsand processed foods Stop food that causes Stop food that causes

allergy stomach or allergy stomach or other discomfortother discomfort

Less red meatLess red meat Increase dietry Increase dietry

fibrefibre Drink plenty of Drink plenty of

waterwater less fat and less fat and

carbohydratescarbohydrates

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Supplements for anxietySupplements for anxietyB and C vitaminsB and C vitamins

Calcium and magnesium supplementsCalcium and magnesium supplements

Relaxing herbRelaxing herb

KavaKava

ValerianValerian

St johns wortSt johns wort

PassionflowerPassionflower

Gotu kolaGotu kola

Ginkgo bilobaGinkgo biloba

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Problems solving Problems solving approachapproach

Defining the problemDefining the problem(1) helpful in making a positive change (1) helpful in making a positive change

(2) specific (2) specific

(3) is the outcome likely to be (3) is the outcome likely to be measureablemeasureable

Steps in problems solvingSteps in problems solvingthinking about possible solutionsthinking about possible solutions

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

looking at the cost and benefit of each looking at the cost and benefit of each solutionsolution

choose the most appropriate (realistic) choose the most appropriate (realistic) solutionsolution

now break down this solution into as now break down this solution into as many steps as possiblemany steps as possible

execute your planexecute your plan

review your outcomereview your outcome

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Practice problem solvingPractice problem solving

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Identifying and expressing Identifying and expressing feelingsfeelings

Identifying feelingsIdentifying feelingsExercise on recognizing moodsExercise on recognizing moodsDiscriminate feelingsDiscriminate feelingsMood diaryMood diaryMeditation and mindfulnessMeditation and mindfulness

Symptoms of suppressed feelingsSymptoms of suppressed feelingsanxietyanxietydepressiondepressionpsychosomatic symptomspsychosomatic symptomsmuscle tensionmuscle tension

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

What are the common types of What are the common types of emotions emotions

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Common types of emotions Common types of emotions

DepressedDepressed Anxious Angry Anxious Angry Ashamed Excited Ashamed Excited

FrightenedFrightened Irritated Panicky Irritated Panicky Frustrated happy Frustrated happy

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

How to be aware of feelingsHow to be aware of feelingsRelaxation breathing Relaxation breathing

Mindfulness Mindfulness

Ask yourselfAsk yourself

Tune into the place of emotions (heart Tune into the place of emotions (heart abdomen mind)abdomen mind)

Wait and listenWait and listen

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Ask the patient how heshe might feel Ask the patient how heshe might feel when in these situations when in these situations

you have failed the examyou have failed the exam you have lost your jobyou have lost your job you are lying in your bed and you hear a you are lying in your bed and you hear a

big explosionsbig explosions you have been caught while stealing you have been caught while stealing

from a shopfrom a shop your friend has told you off for no your friend has told you off for no

reasonsreasons you have been offered a jobyou have been offered a job

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Dealing with cognitive Dealing with cognitive errorserrors

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Teaching on thoughts Teaching on thoughts

What are thoughts (types)What are thoughts (types) How to distinguish them from How to distinguish them from

emotionsemotions Negative automatic thoughtsNegative automatic thoughts

They are automaticThey are automatic - -

They are unhelpful -They are unhelpful -

They are believable - They are believable -

They are persistent They are persistent

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Types of thoughts Types of thoughts Jumping to conclusionsJumping to conclusions

Selective abstractionSelective abstraction

OvergeneralisationOvergeneralisation

Magnification or minimisationMagnification or minimisation

PersonalisationPersonalisation

All or nothing thinkingAll or nothing thinking

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

How to discover thoughtsHow to discover thoughts

Exploring cognitive errors Exploring cognitive errors

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Thought diariesThought diaries

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Situation What Who When Where

Mood Feeling sensations

Thoughts(Words images or memories)

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Situation What Who

When Where

Mood Feeling

sensations

NegativeAutomaticthoughts

EvidenceThatSupportsThe thoughts

Evidencethat doesNotSupporttheThought

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Situation What WhoWhenWhere

Mood Feeling sensations

NegativeAutomaticthoughts

EvidencethatSupportsthethoughts

Evidencethat doesnotsupporttheThought

AlternativeThought(s)

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

questions to help in questions to help in thinking of evidencethinking of evidence that does that does not support the thoughtsnot support the thoughts what would my brothersisterfriend would think if in a what would my brothersisterfriend would think if in a

similarsimilarsituationssituationswhat would have I thought if this had happened in the past what would have I thought if this had happened in the past

ororwhen I was not so depressedanxiouswhen I was not so depressedanxiouswhat would I think if this happens few moths from now onwhat would I think if this happens few moths from now onwhen I am a little betterwhen I am a little betterif my friend was thinking like this what would have I saidif my friend was thinking like this what would have I saidtry to think of similar situations in the past and what did try to think of similar situations in the past and what did

youyouthink thenthink then

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs

Dysfunctional beliefs and Dysfunctional beliefs and assumptions assumptions

Use of youngs schema questionnaireUse of youngs schema questionnaire Downward arrow techniqueDownward arrow technique Education and awareness of beliefsEducation and awareness of beliefs Specific techniques to change beliefsSpecific techniques to change beliefs