Treatments for Anxiety

Stacy Shaw Welch, PhDAnxiety and Stress Reduction Center (ASRC) of Seattle

June 2, 2010FCAP Seminar Series / Partners for our Children

Overview

Part 1 – Understanding anxiety Part 2 – Treating anxiety: First line

treatment approaches for anxiety Part 3 – Concepts of Modular

Treatment (moving from Evidence Based Treatment to Evidence Based Practice)

Part 4 - Introduction to Modules for Anxiety Treatment

Fear, Anxiety, and Anxiety Disorders

What is anxiety?

Fear: focused response to a known or definite threat Fight or flight response Necessary for survival

Anxiety: fear response in the absence of clear danger (anticipation or possibility)Universal experience / wide range of

normalCan be useful/ functional

What is an anxiety disorder?

Persistent anxiety over time around situations that are not objectively dangerous / anxiety not appropriate to developmental level

CausesMarked distressImpairment in functioning Note: this can be obvious or more

subtle in children (e.g., family system is organized around child’s anxiety)

Anxiety vs. Anxiety Disorder

More a matter of degrees Example of separation anxiety:

Normal / functional at specific developmental stages

Some children show increased S.A. as a result of traumatic conditioning

Some children show increased S.A. with no traumatic conditioning

Some children would have such severe or longlasting symptoms that it would meet criteria for a disorder

Anxiety disorders

Separation anxiety disorder Specific phobia Social phobia Panic disorder/agoraphobia Generalized anxiety disorder (GAD) Posttraumatic stress disorder (PTSD)/

Acute stress disorder (ASD) Obsessive compulsive disorder (OCD)

Development of Anxiety

Biology + learning Genetics, temperament clearly influence

who becomes anxious Environment powerful source of learning

and continued “wiring” of the brain to either anticipate• lack of control and danger or • safety and resources to cope

Transaction between the two continues over the lifespan –this is the tragedy and great hope

Development of Anxiety

Another important transaction: the interaction of anxious behaviors and the environment Anxiety “pulls” for certain behaviors

from the environment These environmental responses can

further reinforce anxiety and prevent corrective learning experiences

Treating Anxiety: Brief Review of Research

Treatment

Two main treatment approaches for children, teens and adults CBT – by far most well researched

and effective treatment for anxiety. Should be first-line intervention, combined with meds for moderate or severe disorder.

Medication – SSRIs first, then augmentation strategies

What is CBT?

-Skills based, problem-solving, very practical approach to emotionally driven problems/behaviors

-Patients learn to take “bite-sized” small steps towards health

-Biopsychosocial model as opposed to purely biomedical model

Should include at least 4 elements: education/monitoring, tools to calm physiology, cognitive restructuring, exposure

What kinds of problems can it be used for? Think behavior change, esp. emotionally driven behaviors Depression * Anxiety disorders** Unexplained medical illness / somatization Chronic pain management Eating disorders (bulimia and binge eating) Insomnia (primary and secondary) Addictions Non-adherence to medical recommendations Lifestyle / Behaviors linked to chronic disease care (physical activity,

diet, social support, medications, etc.) Child internalizing and depressive disorders** Marital distress Anger

Specific Approaches to Anxiety Treatment

Adults: a manual (or two, or three) for each anxiety disorder Children: Not much until 1980’s (DSM-III) Early approaches: adult techniques and theories with child-

language Major studies / treatments to know:

CBT for anxiety: “Coping Cat”, “Coping Koalla (Kendall, Barrett)

Talking Back to OCD: ERP (March), POTS CAMS (meds plus CBT) TFCBT – Trauma – focused CBT Modular treatments emphasizing exposure (Chorpita)

Conceptual framework for Modular Treatment of

Anxiety

Modular treatment

Addressing what happens when you try to apply evidence based treatment in community settings with Complex clients Complex situations Logistical challenges (e.g., time)

Evidence-based treatmentsvs. practice Evidence-based treatments

“interventions or techniques that have produced therapeutic change in controlled trials” (Kazdin, 2008)

Evidence-based practice “clinical practice that is informed by evidence

about interventions, clinical expertise, and patient needs, values, and preferences and their integration in decision making about individual care” (Kazdin, 2008)

Protocol-based treatment

Strong trend over the last 25 years toward the development of standardized, protocol-based treatments (i.e., treatment manuals)

Protocol characteristics:Disorder specificStep-by-step list of interventionsSame set of procedures across clientsDissemination and training is generally

needed for each protocol

Pros and cons

Pros Significant advances in the scientific study of

psychotherapy (treatments are replicable) Improved treatment outcomes Greater consistency and quality of care

Cons Problems with dissemination Overlap and redundancy across protocols Multiple protocols for the same disorder Don’t address co-morbidity Decreased flexibility in treatment Encourage disorder-specific thinking

Modular-based treatment

Emerging trend in recent years toward more modular, flexible approaches to treatment

Modular approaches provide a set of overarching principles and a set of evidence-based interventions (“modules”)

Not all modules are necessarily used with each client and the order of modules may vary from client to client

Decisions about which modules to use and in what order are based on the unique symptom patterns of each client

Modular treatment and anxiety

Anxiety disorders lend themselves well to a modular treatment approach because… They share many of the same features and

symptoms A CBT conceptualization of anxiety can be

applied across the disorders There is considerable overlap in the interventions

that comprise the treatment protocols for the various disorders

Modular approaches have been developed for treating anxiety in children/adolescents (Chorpita, 2006) and somewhat with adults (Barlow et al., 2004; Sullivan et al., 2007)

Basic CBT model of anxiety

Physical sensations(physiological arousal)

Behaviors (avoidance, safety behaviors)

Thoughts(perception of threat)

Anxiety

Safety behaviors

Anxious people often engage in a range of behaviors to make themselves feel safer when they cannot avoid anxious situations

These behaviors are attempts to neutralize feelings of anxiety

Although these behaviors can facilitate functioning, they also prevent recovery

Examples Reassurance seeking Over-preparation Behavioral rituals Safety cues/objects

Integrated CBT Model of Anxiety Disorders

Fear Stimulus(trigger or cue)

Misinterpretation of Threat

Anxiety

Avoidant Coping(primary and secondary)

Absence of Corrective Experience and Learning

Pre-existingBeliefs

EnvironmentalFactors

Components of the model

Fear stimulus/trigger Anxiety is almost always cued

Misinterpretation of threat Primary cognitive distortions in anxiety

(1) Overestimating the likelihood of negative outcomes (2) Catastrophizing

Avoidant coping Primary avoidance – avoiding triggers altogether Secondary avoidance – engaging in safety behaviors

when complete avoidance is not possible

Absence of corrective learning New learning does not occur and the fear is maintained

(and often strengthened)

Separation anxiety disorder

Fear Stimulus(trigger or cue)

Misinterpretation of Threat

Anxiety

Avoidant Coping(primary and secondary)

Absence of Corrective Experience and Learning

- Separating from parent at school.- Going to a friend’s house for a sleep-over.

- My mom/dad might die.- Something bad might happen to my mom/dad.

- Panic symptoms, crying

- Primary avoidance: Refuse to leave house/car; call home to be picked up

- Secondary avoidance: Separates but only if can call parent repeatedly to seek reassurance that he/she is okay; has to carry cell phone at all times

Specific phobia (flying)

Fear Stimulus(trigger or cue)

Misinterpretation of Threat

Anxiety

Avoidant Coping(primary and secondary)

Absence of Corrective Experience and Learning

- Needing to fly for a business trip.- Needing to fly for a family vacation.

- Something will go wrong with the plane.- The plan will crash and I will die.

- Increased heart rate, shallow breathing

- Primary avoidance: Avoid going on the trip; get someone else to attend the business meeting; family drives to vacation spot instead of flying

- Secondary avoidance: Sit next to “safe” person; distract self for entire flight; seek reassurance from others about airline safety; drink alcohol or take Xanax before/during the flight (adults)

Social phobia

Fear Stimulus(trigger or cue)

Misinterpretation of Threat

Anxiety

Avoidant Coping(primary and secondary)

Absence of Corrective Experience and Learning

- Having to give a presentation in front of the class.- Needing to ask a question in a store.

- I will sound stupid. My mind will go blank.- I will be an inconvenience. He will be annoyed.

- Increased heart rate, sweating, lightheaded

- Primary avoidance: Skip class; avoid asking the question

- Secondary avoidance: Look down at notes during the entire presentation; talk quickly; over-prepare for presentation; overly apologetic when asking question

Panic disorder

Fear Stimulus(trigger or cue)

Misinterpretation of Threat

Anxiety

Avoidant Coping(primary and secondary)

Absence of Corrective Experience and Learning

- Exercising and heart rate starts to increase.

- I am going to have a heart attack.- I am going to pass out.

- Panic symptoms (increased heart rate, shallow breathing, sweating, dizziness)

- Primary avoidance: Stop exercising; leave the gym

- Secondary avoidance: Repeatedly check heart rate; call doctor office; go to urgent care center; seek reassurance from friend; carry water and cell phone at all times at gym

GAD

Fear Stimulus(trigger or cue)

Misinterpretation of Threat

Anxiety

Avoidant Coping(primary and secondary)

Absence of Corrective Experience and Learning

- Trying to call spouse and he/she is not answering.

- Something must have happened.- He/she was in an accident.

- Restlessness, muscle tension, increased heart rate

- Primary avoidance: N/A

- Secondary avoidance: Repeatedly calling spouse at multiple numbers (work, cell phone) until reaching him/her; keep busy and try to distract self until spouse is home

PTSD (sexual assault)

Fear Stimulus(trigger or cue)

Misinterpretation of Threat

Anxiety

Avoidant Coping(primary and secondary)

Absence of Corrective Experience and Learning

- Walking home from bus stop after work at dusk.

- I am not safe.- Someone could assault/rape me on the way home.

- Increased heart rate, shallow breathing, upset stomach

- Primary avoidance: Avoid taking the bus; drive to and from work; call someone for a ride

- Secondary avoidance: Have someone walk with him/her between bus stop and home; talk on cell phone during entire walk home; walk quickly; carry pepper spray in hand during walk

OCD (checking)Fear Stimulus(trigger or cue)

Misinterpretation of Threat

Anxiety

Avoidant Coping(primary and secondary)

Absence of Corrective Experience and Learning

- Turning off the stove after cooking breakfast.

- What if I left the stove on? - It could burn down the house.

- Increased heart rate

- Primary avoidance: Avoid eating breakfast foods that require using the stove

- Secondary avoidance: Repeatedly check the stove

before leaving the house; drive back home mid- day from work to check the stove; call neighbor to check on the house; mentally review memory of turning off the stove throughout the day

Shared processes to target

There are a set of anxiety processes that are important to target regardless of which anxiety disorder is being treated Maladaptive thoughts that contribute to

perceptions of threat in safe situations Physiological reactivity in response to fear

triggers Avoidance behaviors that prevent the habituation

of fear Safety behaviors that prevent new learning Problematic reinforcement of anxiety by the

environment

Good news…

We have very effective CBT interventions for the processes common to the anxiety disorders!

Process/problem Intervention Misperception of threat Cognitive restructuring

Physiological reactivity Relaxation skills

Avoidance behaviors Exposure**

Safety behaviors Response prevention

Reinforcement of anxiety by environment

Contingency management

Modular treatment for anxiety

A modular CBT approach to treating anxiety involves…Assessing which anxiety processes are

most prominent for each clientSelecting the evidence-based

interventions (“modules”) that are effective for treating these processes

Sequencing these modules to address the unique characteristics of each client and his/her environment

CBT “modules” for anxiety Psychoeducation Self-monitoring Relaxation skills Cognitive restructuring Response prevention Exposure* Parenting techniques Changing environmental

contingencies/responses Relapse prevention Others: social skills, emotion regulation, behavioral

activation, motivational interviewing….

Flexible modules

Flowchart for a standard manualized CBT protocol

Learning about

Anxiety

Relaxation

Cognitive

Restructuring

Exposure

Rewards / Practice

Maintenance

Fear

Ladder

Finish

Modular CBT protocol – (Just get to Exposure)

Fear

Ladder

Learning

about

Anxiety

child ready

to practice?

in vivo

possible?

Imaginal

Exposure

In Vivo

Exposure more items

to practice? Maintenancee Finishno

yes

yes yesno

Interference

no

Modular flowchart for treatment planning

Fear

Ladder

Learning

about

Anxiety

child ready

to practice?

in vivo

possible?

Imaginal Exposure

In Vivo Exposure

more items

to practice? Maintenance Finish

moderate

disruptive

behavior?

parents

rewarding

avoidance?

low

motivation?other

mild disruptive

Behavior?

negative

beliefs or

depression?

social skills

deficits? troubleshoot

Time-Out

Cognitive Restructuring:

Probability

Active Ignoring

Cognitive Restructuring:

STOP

bright, verbal, or older?

Cognitive Restructuring: Catastrophic

Rewards Social Skills:

Meeting People

Social Skills: Nonverbal

no

yes

yes

yes yesno

no

no

Modular flowchart for treatment planning

Fear

Ladder

Learning

about

Anxiety

child ready

to practice?

in vivo

possible?

Imaginal

Exposure

In Vivo

Exposuremore items

to practice?Maintenance Finish

moderate

disruptive

behavior?

parents

rewarding

avoidance?

slow

motivation?other

mild disruptive

Behavior?

negative

beliefs or

depression?

social skills

deficits? troubleshoot

Time-Out

Cognitive

Restructuring:

Probability

Active

Ignoring

Cognitive

Restructuring:

STOP

bright, verbal,

or older?

Cognitive

Restructuring:

Catastrophic

RewardsSocial Skills:

Meeting

People

Social Skills:

Nonverbal

no

yes

yes

yes yesno

no

no

CBT “modules” for anxiety

Psychoeducation Self-monitoring Relaxation skills Cognitive restructuring Response prevention Exposure* Parenting techniques Changing environmental

contingencies/responses Relapse prevention Others: social skills, emotion regulation, behavioral

activation, motivational interviewing….

Flexible modules

Psychoeducation Key to helping clients understand their symptoms and

the treatment model Psychoeducation should include both:

Disorder specific information Review of the integrated CBT model of anxiety

Helpful to fill out the model with the client using examples from his/her life Kids- maps, posters, etc.

Could be used for anxiety disorder or “normal” anxiety (will be validating if not anxiety reducing)

Could be used for parents dealing with anxiety, even without anxiety disorder

Integrated Model of Anxiety -Client Handout

Fear Stimulus(trigger or cue)

Misinterpretation of Threat

Anxiety

Avoidant Coping(primary and secondary)

Absence of Corrective Experience and Learning

Pre-existingBeliefs

EnvironmentalFactors

Self-monitoring

Critical part of problem/ symptom assessment Helps client recognize the different components of

their anxious reactions (“anxiety is not a lump”) Helps clients identify patterns in responses

Elements of self-monitoring for anxiety include: Triggers/cues for anxiety Intensity ratings for anxiety (SUDS) Physical sensations Anxious thoughts Anxious behaviors (avoidance, safety behaviors) Young kids would do with caretaker

Self-monitoring example - panic

Situation/trigger Standing in line at a store

Intensity of anxiety (0-10) 7

Physical sensations/other symptoms

Increased heart rate, shallow breathing, sweating

Anxious thoughts(words or images)

“I am going to have a panic attack,” “I won’t be able to get out of here in time”

Anxious behaviors(e.g., avoidance, safety behaviors, rituals)

Put my merchandise down and left the store; went to sit on a bench to calm down; took a Xanax

Self-monitoring example - OCD

Situation/trigger Hitting a bump in the road while driving

Intensity of anxiety (0-10) 9

Physical sensations/other symptoms

Increased heart rate

Anxious thoughts(words or images)

“What if I hit someone with my car?”

Anxious behaviors(e.g., avoidance, safety behaviors, rituals)

Drove around the block 4 times to check for injured pedestrians; mental retracing

Relaxation Relaxation skills target physiological reactivity

associated with anxiety and worry Two main skills are

Diaphragmatic breathing – targets acute panic/anxiety reactions

Progressive muscle relaxation – targets chronic muscle tension associated with ongoing anxiety/worry

Important to be realistic about how effective these skills are in reducing anxiety

Could be taught for anxiety disorder or “normal” anxiety Creative ways to teach children (bubbles, snake, tire)

Relaxation Disorder specific recommendations

Breathing re-training is a standard part of treatment for panic disorder

PMR is a standard part of treatment for GAD Neither tends to work that well for OCD

General recommendations Consider using with children and adolescents

regardless of disorder Consider using with adults regardless of disorder

when physiological symptoms are prominent and/or interfere with treatment

Coach clients not to use relaxation skills during exposure exercises

Exposure

Exposure is staying present with the feared stimulus long enough for new learning to

occur

(assuming that fear is not really dangerous)

Habituation and anxiety

Anxiety

Time

Exposure Three golden rules of exposure:

1. Fears are faced gradually, moving from least to most difficult

2. The client must stay in the feared situation long enough to learn that the bad things s/he fears will not happen.• If withdrawal occurs to quickly-fear can increase

3. Practice and repetition are the keys to success• If withdrawal occurs to quickly-fear can increase

Exposure

Process of exposure is similar across the anxiety disorders, what varies is the fear trigger Separation anxiety – separation from caregiver Specific phobia – feared object/ situation Social phobia – social/performance situations Panic/agoraphobia – physical sensations of

panic/avoided activities and situations GAD – worry scenarios/images and worry

triggers PTSD – trauma memories and triggers OCD – triggers for obsessions and obsessive

thoughts themselves

Exposure: Build a Hierarchy

First, externalize anxiety Teach children how to identify and rate anxiety

Fear thermometer / worry scale Anxiety list, “bravery ladder”, map Case example: “Jayden”, 9 year old boy with GAD, mild

OCD• Very significant worries in a wide range of areas – academic,

medical, social, getting hurt, making any mistake• Adopted at age 4 out of foster care system, very early

abuse/neglect• Significant risk and protective factors

Example: Jayden, GADSituation Worry Scale

High Getting a shot Teacher yelling at me Making mistakes on testsFalling and getting hurt at school Forgetting my homeworkSeeing bloodThinking about robbersGetting a bad gradeGoing to a new place

109888898109

Medium Being late for schoolForgetting a library bookMaking a mistake on homeworkMeeting new peopleLaundry machine

778755

Low Chatting at schoolPlaydates

43

Exposure hierarchy example – separation anxiety

SUDs

Trigger

10 Going to an overnight camp

9 Spending the night at a friend’s house

8 Staying with grandma – both parents out of town overnight

7 One parent out of town overnight

5 2 hour play-date (no parents present)

3 1 hour play date (no parents present)

1 Playing alone in room (parents outside in yard)

Exposure hierarchy example – PTSD (car accident)

SUDs

Trigger

10 Driving on freeway where accident happened

8 Talking about the memory of the accident

7 Watching a car accident in a movie/TV show

5 Driving on a busy road at rush hour

4 Driving on a busy road not at rush hour

3 Driving in a busy parking lot

2 Driving around the block

1 Sitting in driver’s seat of car in driveway

Exposure hierarchy example – GAD

SUDs

Trigger

10 Imagining spouse dying in car accident

9 Reading article about cancer

8 Imagining being fired from job

6 Imagining son failing out of college

5 Watching evening news

5 Imagining being poor in retirement

4 Reading article about bankruptcy

3 Making a decision and not reversing it

Exposure hierarchy example – panic (interoceptive exposure)

SUDs

Trigger

10 Running in place for 5 minutes (heart rate)

9 Spinning in chair for 1 minute (dizziness)

7 Straw breathing for 1 minute (not enough air)

6 Over-breathing for 1 minute (hyperventilating)

5 Walking up 1 flight of stairs (heart rate)

4 Sitting in heated car for 3 minutes (heat)

3 Standing up quickly (dizziness)

Tips when doing Exposure

If in doubt, start low Conduct first exposure in session, if possible

Research on therapist – assisted exposure in OCD Schedule adequate time Prep and orient, but don’t drag out Be aware of your style

Confident Lots of praise esp. following exposure Coach

Balance distraction/coping with focus on anxiety sensations

Debrief afterwards to promote learning

Case Example Case example – Jayden

Taught breathing and relaxation to entire family Started exposure with a low anxiety / high probability of

success item (talking to a new person at our office), then extended to saying hello to baristas at coffee shops , then moved to saying hello to more people at school

Gradually reduced reassurance seeking (cut by 50% as directed by child, with reward system). Worked with Mom to decrease overprotective behaviors and increase reinforcement for “brave” behaviors

Exposure, cont.

Eventually did “silly” things (say hi in a foreign language, wear our shirts inside out downtown)

Moved up hierarchy with parents gradually coaching more at home during exposures (e.g., laundry).

Laundry: play reward game near laundry, then sitting on machine, then put clothes in laundry, then imagine being sucked in laundry with therapist

What about traumatized kids / “normal” anxiety?

Exposure to actual danger makes fear increase Exposure when situation is not dangerous will

create decreased fear over time Consider adding safety cues to help lower anxiety

level• Talk it through, focus their attention externally, validate fear• Add safety cues (reassurance, praise)• If needed use distraction• If anxiety can’t be tolerated – avoid and try to come back

later Examples:

• Dentist / therapy dog• Little Bear – “the clam”

Cognitive restructuring

Clients learn to: Identity anxious thoughts Evaluate / challenge unhelpful or maladaptive thoughts Generate more balanced, accurate thoughts Coping thoughts must be believable and not just “positive

thinking”

Rehearsal Before anxious situations During anxious situations With practice, balanced thoughts come more

automatically

Cognitive distortions in anxiety

General

Overestimating the likelihood of negative outcomes (“jumping to conclusions”)

Catastrophizing (“worst case”)

Cognitive restructuring strategies

Overestimating likelihood of negative outcomes: Identify all other possible outcomes to help determine the “real odds” of the feared outcome

Catastrophizing: Generate a list of ways to cope with the worst case scenario

Cognitive restructuring

Tread carefully and use validation

Think developmentally

Focus on helpfulness vs. accuracy

If thoughts are resistant to change, back off and try again in another way or at another time

Cognitive restructuring example – separation anxiety Anxious thought: If my mom goes to work (at a

college campus) she will get shot and killed.

Cognitive restructuring: Evidence for: There have been several shootings

at colleges recently Evidence against: There has never been a

shooting at her campus; she has been to work hundreds of time and has always come home safely; she’s never been injured at work at all

Coping thoughts: My mom will likely be okay at work. Her campus seems to be pretty safe.

Cognitive restructuring example – social anxiety Anxious thought: If I go to happy hour with my co-

workers I won’t be able to come up with anything to say and I will look weird.

Cognitive restructuring: Other possible outcomes: I am able to say

something; I listen to others and just ask questions; I sit quietly and nobody notices; other people are quiet too. Real odds: Low.

Coping with worst case: I could excuse myself to the bathroom and try to think of some things to talk about; I could think of ideas now before I go

Coping thoughts: I will probably feel anxious but I can come up with at least 1 thing to say. I am not responsible for 100% of the conversation.

Cognitive restructuring example – panic Anxious thought: I feel lightheaded. I am going to

pass out and make a scene.

Cognitive restructuring: Other possible outcomes: I might not faint – I never

have before; I feel lightheaded because I am anxious; the feeling will probably pass after a while. Real odds: Low.

Coping with worst case: If I fainted other people around would probably help me; I would feel embarrassed but that would pass too – I could tell people that I have a medical condition

Coping thoughts: I been lightheaded many times and have never fainted. I am not likely to faint but if I do other people will help me and I won’t feel embarrassed forever. You don’t die from fainting!

A caveat about OCD

Cognitive restructuring can be problematic when treating OCD

Core feature of OCD is a difficulty tolerating doubt and uncertainty

Cognitive restructuring can play right into this difficulty and often does not “stick” due to lingering doubts

Can use the strategies to focus on beliefs about thoughts vs. the content of the thoughts themselves

Cognitive restructuring example - OCD Anxious thought: If I have a bad thought

something bad will happen to someone I love (example of thought action fusion)

Cognitive restructuring: Socratic questioning about whether thoughts can

impact events in the world Behavioral experiments to test this out – think

about something falling from the sky and see if it does; think about a bug dying and see if it dies; work up to more difficult experiments about others being harmed by client’s thoughts

Response prevention

Drawn from OCD treatment, but can be used broadly across anxiety disorders

Response prevention can be thought of as the process of blocking any behaviors that are an attempt to neutralize anxiety (i.e., safety behaviors)

Exposure less effective without RP, so its good to start before starting exposure if possible

Often overlooked

Response prevention - steps

Identify safety behaviors

Develop a plan to reduce and eliminate them (this can be put on your exposure hierarchy)

Goal is to work toward full response prevention whenever possible (i.e., elimination of all safety behaviors)

For severe anxiety, esp. health anxiety or OCD, might have to start with response prevention

Response prevention example – driving phobia

Safety behavior Response prevention plan

Listen to talk radio as a distraction

Lower volume of radio over time until radio is off altogether

Carry full bottle of water in front seat of car whenever driving

Switch to half empty bottle, then mostly empty bottle, and then no bottle

Always drive in the slow lane on freeway

Switch from slow lane to center lane and then to fast lane

Response prevention example – OCD (child)

Ritual/compulsion Response prevention plan

30 minute checking sequence before bed

Decrease checking in steps, eliminating 1 or more components each week

Change clothes after coming in from outside

Decrease number of articles of clothing being changed in steps

Confess to others when done something “bad”

Decrease total number of confessions for the day in steps

Response prevention example – GAD

Safety behavior Response prevention plan

Call spouse repeatedly until reach him/her

Call once and then do not call again if don’t reach him/her

Check stock market updates online 15 times per day

Check stock market information once per day

Weigh pros and cons for lengthy period of time before making a minor decision

Make minor decisions within specified time frame (e.g., a few minutes) and don’t undo them

Changing environmental contingencies/responses Assess carefully for:

Reinforcement of anxious behaviors Lack of reinforcement for non-anxious behaviors

Key people in client’s life should be involved in treatment during this module (if not already)

Important to keep client in driver’s seat as much as possible

Changing the environment – child client (OCD) Problem: Anxious child with OCD whose

parents participate in many of the child’s rituals to help decrease her anxiety

Solution: Educate the parents about the role that their

behaviors play in perpetuating the child’s anxiety Provide a clear rationale for why these behaviors

need to change for the child to get better Teach parents how to reinforce non-anxious

behaviors Provide a road map for when parents should stop

participating in various rituals Assist parents as needed in tolerating their own

anxiety about their child’s discomfort

Changing the environment – adult client (panic/agoraphobia) Problem: Anxious adult with panic disorder and

agoraphobia who cannot go out in public without spouse (i.e., the spouse is a primary safety cue)

Solution: Educate the spouse about the role that his/her

behaviors play in perpetuating the client’s anxiety Provide a clear rationale for why these behaviors

need to change for the client to get better Provide a road map for when the spouse should

stop going various places with the client Teach spouse how to reinforce non-anxious

behaviors Assist the couple in adjusting to new roles as the

client becomes more independent

Relapse prevention

Important to develop a relapse prevention plan with all clients prior to ending treatment

Typical elements of this plan include: List of possible triggers that could lead to relapse

of anxiety or other symptoms Plan for how to use skills learned in treatment to

cope with these triggers Plan for how to identify and respond to new

triggers and/or symptoms List of supports to enlist for help as needed Guidelines for when to return for booster

sessions or a new course of treatment

Summary

Modular treatment approaches use evidence based principles and interventions in a flexible way that allows for individualized treatment planning

Approaching the treatment of anxiety in a modular way can highlight the commonalities among these disorders and how they are treated

Focus is on doing what is likely to work for the unique symptom presentation of each client, within a framework of evidence-based practice

If you know one CBT treatment for anxiety well, a lot of your knowledge will transfer to treating other anxiety disorders!