Specific Phobias

1
Specific Phobias GAD

• JONATHAN GASTON
• DIRECTOR EMOTIONAL HEALTH CLINIC
• CENTRE FOR EMOTIONAL HEALTH

2
Defining Fear/Anxiety

• Fight-Flight Response
• A necessary inbuilt protective response mechanism
  to protect us from danger and help us survive
• Only a problem when
• Mechanism is switched on when we dont want it to
  be
• OR
• The intensity of the response seems out of
  proportion to the actual danger

3
Physiological Anxiety Response

• Rapid heart, heart palpitations, pounding heart
• Sweating
• Trembling or shaking
• Shortness of breath or smothering sensations
• Dry mouth or feeling of choking
• Chest pain or discomfort
• Nausea, stomach distress or gastrointestinal
  upset
• Cold chills or hot flushes
• Dizziness, unsteady feelings, lightheadedness, or
  faintness
• Feelings of unreality or feeling detached from
  oneself
• Numbing or tingling sensations
• Visual changes (e.g., light seems too bright,
  spots, etc.)
• Blushing or red blotchy skin (especially around
  face)
• Muscle tension, twitching, weakness or heaviness

4
Neurobiology of Anxiety (Stein et al., 2007
Etkin Wager, 2007)

1. Amygdala Hyperactivity central to fear
   conditioning
2. Insula Hyperactivity regulates autonomic nervous
   system and associated with interoceptive awareness

5
CBT MODELS ANXIETY
6
Traditional A-B-C Model of CBT

• Linear
• Unidirectional
• Thoughts cause feelings
• A B C D
• Situations Thoughts Feelings Behaviour
• Focus is on challenging irrational thoughts
  (cognitive restructuring)

7
More Current CBT Model

• Thoughts
• Physiology Mood/Emotion
• Behaviour
• Non-linear
• Integrative
• All components of equal importance

8
Final Cognitive Pathway Model
Physiology (Physical Symptoms)
Mood/Emotion
COGNITION
More Conscious
More Automatic
Behaviour
Perception/Attention
Environment
9
Cognitive Pathway Model

• Cognitive, behavioural, emotional, physiological
  and attentional approaches are potentially
  synergistic not antagonistic
• Humans always employing cognitive processes in
  solving any problem- whether these processes be
  more automatic or more conscious in nature
• Different common pathways (eg., conditioning,
  observational learning, cognitive challenging,
  emotional processing, mindfulness) lead to same
  final common pathway
• Action on an underlying cognitive belief
  structure

10
Final Cognitive Pathway Model for Anxiety
Anxiety Symptoms Fight or Flight Response
Anxiety/Fear Apprehension
DANGER/THREAT APPRAISALS
Probability Cost
Safety Behaviours Avoidance Escape Neutralising
Hypervigilance for Danger Scanning for
threat Look for confirming evidence
Environment
11
Aim of Treatment for Anxiety

• To modify danger/threat appraisals to become
  more realistic and adaptive

12
In Designing Treatment for Anxiety

• Key in Assessment What are the specific
  danger/threat expectancies?
• Key in Treatment What factors are currently
  maintaining the specific danger/threat
  expectancies?
• Order of Effectiveness in Learning (Reiss, 1980)
• Experience
• Observation
• Symbolic (e.g., language)

13
CBT for Anxiety - Cognition

• Key need to address both probability and cost
  with some fears
• Also need to consider Metacognition' - beliefs
  about the problem itself
• problem (causes, maintenance, costs, benefits)
• utility of current coping strategies (general)
• specific safety strategies
• change
• self-efficacy
• coping with actual physiological sx. (are sx.
  harmful?)

14
CBT for Anxiety - Behaviour

• Key How is the client's behaviour maintaining
  their threat appraisals?
• Safety Behaviours
• avoidance escape behaviours
• proactive (neutralising) behaviours
• 'subtle' in-sitn. safety behaviours
• cognitive safety behaviours

15
CBT for Anxiety Physiology Emotion

• traditionally a control-based approach
• now less emphasis than previously
• relaxation can useful as general stress/anxiety
  reduction tool
• be careful intervention strategies do not become
  safety behaviours
• often treatment (exposure) will involve
  increasing Sx.
• symptom surfing - increase coping
• symptom exposure increase tolerance
• short term gain vs. long-term change

16
CBT for Anxiety - Attention

• attentional focus can interfere with the
  processing of information from feared situations
  (selective filter)
• client needs to process 'range' of perceptual
  evidence
• 'task-focussed attention'
• 'mindfulness' (being in the moment)
• how best to train???

17
Do Psychotherapies produce Neurobiological
effects? (Kumari, 2008)

• Emerging empirical evidence to demonstrate that
  psychological therapies produce changes at the
  neural level
• Paquette et al., (2003)
• Successful CBT modified neural activity in the
  dorsolateral prefrontal cortex and the
  para-hippocampal gyrus in a group of spider
  phobics
• CBT reduces phobic avoidance by de-conditioning
  contextual fear learned at the hippocampal/parahip
  pocampal region, and by decreasing cognitive
  misattributions and catastrophic thinking at the
  level of the prefrontal cortex

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SPECIFIC PHOBIAS
19
Lohr, Oluntunji Sawchuk (2007)

• The more explicitly danger is signalled in terms
  of location, duration, intensity onset, the
  more specifiable safety signals can be
• Specific phobias provide the best example of a
  danger signal with clearly defined boundaries
  properties
• The safety behaviour of avoidance is often so
  effective that daily life is only minimally
  disrupted
• This may account partially for the significant
  discrepancy between the high diagnostic
  prevalence vs. the low proportion seeking
  treatment (1)

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SPECIFIC PHOBIA - DSM IV

• A. MARKED AND PERSISTENT FEAR THAT IS EXCESSIVE
  OR UNREASONABLE AND CUED BY PRESENCE OR
  ANTICIPATION OF A SPECIFIC OBJECT OR SITUATION.
• B. EXPOSURE TO STIMULUS ALMOST INVARIABLE
  PROVOKES IMMEDIATE ANXIETY.
• C. PERSON RECOGNISES EXCESSIVENESS OF FEAR.
• D. STIMULUS AVOIDED OR ENDURED WITH DREAD.
• E. AVOIDANCE INTERFERES SIGNIFICANTLY WITH NORMAL
  ROUTINE OR FUNCTIONING

21
Specific Phobia - Subtypes

• ANIMAL spiders, snakes, other insects, dogs,
  birds, sharks, etc
• NATURAL ENVIRONMENT storms, heights, water
• BLOOD, INJECTION, INJURY seeing blood or an
  injury, receiving an injection or invasive
  medical procedure (common fainting response)
• SITUATIONAL tunnels, bridges, elevators, flying
  driving, enclosed spaces, driving
• OTHER choking, vomiting, contracting an
  illness, loud noises, costumed characters

22
DANGER/THREAT APPRAISALS IN SPECIFIC PHOBIAS?

• Pain
• Physical/bodily harm
• Illness/Disease
• Death

23
Demographics of Specific Phobia

• LIFETIME PREVALENCE 12.5
• (Kessler et al., 2005)
• AGE OF ONSET YOUNG (ÖST)
• ANIMAL FEARS - lt7
• BLOOD - lt9
• DENTAL - lt12
• SITUATIONAL (CLAUSTRO) - 20
• AGE OF PRESENTATION ??
• SEX DISTRIBUTION FEMALE 21 ratio
• COURSE OF DISORDER UNKNOWN
• DEGREE OF INTERFERENCE LOW
• COMORBIDITY HIGH WITH OTHER ANXIETY DIS
• (Magee et al., 1996)

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HERITABILITY OF SPECIFIC PHOBIAS KENDLER ET AL
(1999)
TYPE HERITABILITY
ANIMAL 47
BLOOD / INJURY 59
SITUATIONAL 46
25
CONDITIONING THEORY OF PHOBIAS
CS UCS
AVOID
(DOG) (BITE) CR UCR (FEAR)
(PAIN/FEAR)
26
PROBLEMS WITH THE CONDITIONING THEORY OF PHOBIAS
- RACHMAN (1970), SELIGMAN (1971)

• MANY AVERSIVE EXPERIENCES DO NOT RESULT IN
  PHOBIAS (E.G. AIR-RAIDS)
• PHOBICS DO NOT OFTEN RECALL CONDITIONING
• PHOBIAS DO NOT EXTINGUISH EASILY
• PHOBIAS OCCUR TO A LIMITED SET OF STIMULI (NO
  EQUIPOTENTIALITY)

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PREPAREDNESS THEORY OF PHOBIAS - SELIGMAN (1971)

• A PREPARED STIMULUS IS ONE WHERE
• FEAR IS ACQUIRED IN A SINGLE LEARNING TRIAL
• THE FEAR IS NON-COGNITIVE
• THE FEAR IS RESISTANT TO EXTINCTION

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SUPPORT FOR PREDICTIONS MADE BY THE PREPAREDNESS
THEORY OF PHOBIAS (McNALLY, 1987)
PREDICTION SUPPORTED
1. FEAR ACQUIRED MORE QUICKLY TO PREPARED CUE X
2. FEAR OF PREPARED CUE MORE IRRATIONAL X
3. PREPARED STIMULI WILL SELECTIVELY ASSOCIATE BETTER WITH PARTICULAR OUTCOMES X
4. PREPARED ASSOCIATIONS WILL BE HARDER TO EXTINGUISH ?
29
Rachman (1976, 1977, 1991)

• Three (learning-based) Pathways to Fear
• Classical conditioning
• Vicarious acquisition through direct or indirect
  observations
• Informational acquisition

30
SPECIFIC THREAT EXPERIENCES IN HEIGHT PHOBIA
(MENZIES CLARK, 1993)
A NON-ASSOCIATIVE ACCOUNT OF FEAR ACQUISITION ?
31
RELATIONSHIP BETWEEN FALLS AND FEAR OF HEIGHTS
(POULTON ET AL, 1998)
SERIOUS FALLS BEFORE AGE 5 SERIOUS FALLS BEFORE AGE 5
FEAR OF HEIGHTS AGE 11 YES NO
YES 4 7
FEAR OF HEIGHTS AGE 18 YES NO
YES 7 12
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RELATIONSHIP BETWEEN FALLS AND FEAR OF HEIGHTS
(POULTON ET AL, 1998)
SERIOUS FALLS AGES 5 TO 9 SERIOUS FALLS AGES 5 TO 9
FEAR OF HEIGHTS AGE 11 YES NO
YES 7 7
FEAR OF HEIGHTS AGE 18 YES NO
YES p lt .05 2 13
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Cognitive Vulnerability Model of Phobias
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Specific Phobia Treatment Issues

• The development of good, well-designed and
  specific exposure hierarchies
• Being innovative in planning exposure (e.g., time
  vs. task)
• Potential benefits of massed exposure/quick gains
  ???
• The client doing enough exposure (dose-response
  issue)
• Dealing with the physical sx. of anxiety while
  doing exposure
• Subtle avoidance which may reduce exposure
  effect (the case for early guided exposure)
• The case for overlearning ???
• Applied tension for fainting in blood-injury
  phobia
• Fear vs. disgust

35
Optimising Exposure (Craske et al., 2008)

• 1. Variability throughout Exposure
• Retention of learned material is enhanced by
  random and variable practice
• While variation increases learning difficulty, it
  enhances long-term outcome
• Variation increases the storage strength of
  information
• Variation results in pairing the information to
  be learned with more retrieval cues, this
  enhancing retrievability
• Variation leads to superior generalization

36
Optimising Exposure (Craske et al., 2008)

• 2. Spacing of Exposure Tasks
• Temporally spaced learning trials may result in
  stronger learning acquisition than massed
• Evidence suggests though that each trial must
  sufficiently violate fear expectancies
• ? Massed X Spaced interaction
• Some evidence for tapering (progressively
  longer intervals between exposure occasions
• 3. Context Effects
• Should conduct exposure therapy in multiple
  contexts, especially those in which the
  previously feared stimulus is likely to be
  encountered once treatment is over

37
Optimising Exposure (Craske et al., 2008)

• 4. Fear Toleration vs. Fear Reduction
• Emotional regulation is potentially dysfunctional
  when applied rigidly to down regulate emotions
  through suppression, control, avoidance or escape
• Persistent attempts to down regulate aversive
  states are often critical to the onset of phobias
  and other anxiety disorders
• Some evidence that sustaining fear responding
  throughout extinction may actually enhance
  extinction learning

38
GENERALISED ANXIETY DISORDER
39
Lohr, Oluntunji Sawchuk (2007)

• The more explicitly danger is signalled in terms
  of location, duration, intensity onset, the
  more specifiable safety signals can be
• Danger signals that transcend time and place
  (unpredictability of onset) make for poorly
  defined safety signal development
• Danger signals in the form of intrusive thoughts
  and worries that are future-oriented and involve
  catastrophic outcomes with objectively low
  probability do not allow for the establishment of
  safety relative to current time and place
• The broad nature of threat will render safety
  seeking behaviour as ill defined and generalised
• Is GAD largely a chronic but unsuccessful search
  for safety ? (Woody Rachman, 1994)

40
GAD DSM-IV Criteria

• EXCESSIVE ANXIETY AND WORRY OCCURRING MORE DAYS
  THAN NOT FOR AT LEAST SIX MONTHS ABOUT A NUMBER
  OF EVENTS.
• DIFFICULTY CONTROLLING THE WORRY
• C. AT LEAST THREE OF THE FOLLOWING
• 1) RESTLESSNESS OR FEELING KEYED UP
• 2) EASILY FATIGUED
• 3) DIFFICULTY CONCENTRATING
• 4) IRRITABILITY
• 5) MUSCLE TENSION
• 6) SLEEP DISTURBANCE
• D. FOCUS OF WORRY NOT ANOTHER AXIS 1

41
DANGER/THREAT APPRAISALS IN GAD?

• Many and varied
• Two key underlying issues
• The world is an unpredictable and unsafe place
• I am ill-equipped to deal and cope with this
  danger and general uncertainty ( a poor coper)
• People with GAD like control and predictability

42
DEFINITION OF WORRYBORKOVEC ET AL. (1983)

• AN ATTEMPT TO ENGAGE IN MENTAL PROBLEM-SOLVING ON
  AN UNCERTAIN ISSUE WITH A POTENTIAL THREAT OUTCOME

43
CONTENT OF WORRIES IN GAD- ROEMER ET AL (1997)
GAD OF TOTAL WORRIES NON-CLINICAL
FAMILY / HOME / RELATIONSHIPS 31.4 28.2
FINANCES 10.8 5.6
WORK / SCHOOL 22.0 36.6
ILLNESS / HEALTH 9.6 9.9
MISCELLANEOUS 26.3 19.7
44
CONTENT OF MISCELLANEOUS WORRIES IN GAD - ROEMER
ET AL (1997)
GAD OF TOTAL WORRIES NON-CLINICAL
PSYCHOLOGICAL/ EMOTIONAL 20.9 28.6
MINOR/ ROUTINE 45.2 7.1
FUTURE 12.2 14.3
SUCCESS/FAILURE 14.8 35.7
TRAVEL 6.9 14.3
45
FEATURES OF WORRY IN GADCRASKE ET AL. (1989)
GAD NON-CLINICAL
DURATION 310.3 237.1
ANXIETY 5.17 3.98
CONTROL 6.00 3.51
REALISM 4.33 2.71
SUCCESS OF STOPPING 2.61 4.50
46
GAD - DEMOGRAPHICS

• GAD has a lifetime prevalence of 5
• GAD affects approximately 400 000 adult
  Australians each year
• Gender ratio Females 60
• GAD makes the top 12 diseases for disability
  adjusted life years lost
• GAD presents a substantial financial cost to the
  community, e.g., high health care costs and lost
  work productivity
• GAD is associated with substantial co-morbidity -
  primarily other anxiety disorders depression

47
DSM-IV DISORDERS AND AFFECTIVE STRUCTURE BROWN
ET AL (1998)
48
Life Interference

• GAD interferes with
• Work and academic functioning/aspirations
• (over under achievement)
• Enjoyment and quality of life
• (chronic cognitive physical arousal,
  avoidance)
• Emotional experience
• (can be aloof or overly-emotional)
• Engagement in interpersonal relationships
• (stress, intimacy, genuineness, avoidance,
  isolation)
• Pure GAD is equally as disabling as pure MDD

49
Course

• GAD has an early onset and a chronic course
• Most people with GAD have always been worriers
• Mean onset is between the teens and late twenties
• BUT, onset may be earlier (children were
  previously diagnosed with overanxious disorder)
• GAD symptoms are chronic and persist for 10 yrs
  or more
• GAD is unlikely to remit spontaneously

50
PROBABILITY OF REMISSION OF GAD (YONKERS ET AL,
1996)
WEEK REMISSION FROM GAD ONLY REMISSION FROM GAD PLUS ALL OTHER ANXIETY
26 0.11 0.03
52 0.15 0.07
104 0.25 0.17
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Contributing Factors?

• Genetics, temperament factors, parenting styles
• Some evidence that people with GAD have more
  insecure attachment styles primarily ambivalent
• Childhood relationships characterized by
  enmeshment with caregivers children had
  inappropriate levels of responsibility
  (parenting their parents)
• Some evidence of heightened levels of early
  trauma
• These factors impact on
• Coping styles and Self-efficacy
• Enhance vigilance and planning for threat, but
  feel poorly resourced to deal with actual threat
  feeling overwhelmed
• Enhance fears of uncontrollability and
  unpredictability
• Children may internalize beliefs about
  vulnerability, weakness, inadequacy

52
FREQUENCY OF DISORDERS IN 1ST DEGREE RELATIVES -
NOYES ET AL. (1987)
53
MODELS OF GAD
54
WORRY AS EMOTIONAL SUPPRESSION - BORKOVEC

• WORRY COMPLETELY SEMANTIC
• FULL EMOTIONAL PROCESSING REQUIRES BOTH SEMANTIC
  AND VISUAL PROCESSING
• HENCE WHEN WORRY - EMOTIONS PROCESSED AT A
  LOWER LEVEL
• THUS WORRY USED TO AVOID COMPLETE EMOTIONAL
  EXPERIENCE
• IN TURN, EMOTIONAL ISSUES ARE MAINTAINED

55
Emotional Avoidance and Regulation 1

• Borkovecs cognitive avoidance model essentially
  says that people with GAD fear intense negative
  emotions
• But he doesnt conceptualise this as another
  threat appraisal that is fuelling worry
• Instead he argues that worry has a function, that
  is, it acts as a form of cognitive avoidance that
  inhibits negative affect through the
  automatic/unconscious inhibition of imaginal
  processing
• This in turn negatively reinforces the use of
  worry as an emotion regulation strategy, which
  dampens anxiety in the short term

56
Emotional Avoidance and Regulation 2

• Mennin et al. (2002, 2004), following from
  Borkovec, have suggested that GAD is a disorder
  of emotion dysregulation involving
• Heightened emotional intensity
• Heightened emotional reactivity
• Maladaptive emotional management
• Poor understanding of emotions

Poor tolerance of emotions
Leading to emotional avoidance
57
RELATIONSHIP BETWEEN WORRY, COPING ANXIETY -
DAVEY (1992)

• PARTIAL CORRELATIONS BETWEEN WORRY AND COPING,
  CONTROLLING FOR TRAIT ANXIETY
• ACTIVE COGNITIVE COPING .26
• ACTIVE BEHAVIOURAL COPING .11
• AVOIDANT COPING .30

58
COGNITIVE MODEL OF GAD(WELLS, 1995)
TRIGGER
POSITIVE META-BELIEFS ACTIVATED (STRATEGY
SELECTION)
TYPE 1 WORRY
NEGATIVE META-BELIEFS ACTIVATED
TYPE 2 WORRY
EMOTION
BEHAVIOUR
THOUGHT CONTROL
59
TYPE 1 Worries (Wells,1995)

• Concern external daily events
• (e.g., health of a partner)
• Concern non-cognitive internal events
• (e.g., bodily sensations)

60
TYPE 2 Worries Meta-worry (Wells, 1995)

• How people appraise (both positive negative)
  the activity and function of worry
• worry about worry
• This meta-worry leads to the client further
  engaging in Type 1 worry
• Can broaden concept to use with other anxiety and
  non-anxiety problems - beliefs clients may hold
  about their problems (origin, nature,
  maintenance, costs benefits)
• Fit/misfit between your treatment model and their
  implicit model will effect engagement and progress

61
A THREAT EXPECTANCY (INTEGRATIVE) MODEL OF
GAD(Abbott Gaston, 2003)
62
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63
Threat Expectancy in GADThe potential for danger
is everywhere!

• Our model suggests that there are five core
  categories of threat expectancy that can be
  activated in GAD
• Situations themselves are potentially threatening
• Potential confirmation of negative core beliefs
  is threatening
• Affect itself is perceived as threatening
• The consequences of not coping are seen as
  threatening
• Worry process itself is perceived as threatening

64
Threat, Affect and Neutralizing

• These ways of perceiving threat may be activated
  in isolation or in combination, and they all feed
  the perceived intensity of worry and anxiety
• Biological/tolerance factors may moderate the
  actual amount of affect experienced
• The cognitive and affective experience of anxiety
  triggers the use of avoidance and safety
  strategies to control potential threat and
  aversive experience

65
Predisposing Factors

• Predisposing factors for GAD include
• A genetic predisposition to negative affect
• Ruminative perseverative cognitive style
• Intolerance of strong negative affect
• Early life experiences
• Parenting styles

66
Negative Core Schemas in GAD

• Predisposing factors lead to the development of
  underlying schema. Themes of negative schema in
  GAD seem to include beliefs like
• I am defective
• I am vulnerable
• I am weak
• I am inadequate/incompetent
• I am worthless
• According to the model, these underlying negative
  schema drive threat expectancies in GAD

67
TE1. Inflated Perceptions of Situational Threat

• Overestimate the probability of negative events
  occurring
• AND
• Overestimate the cost of negative events, should
  they occur
• AND
• Underestimate their ability to cope, should a
  negative outcome occur

68
Intolerance of Uncertainty (Dugas et al., 2004)

• People with GAD find uncertainty threatening
• fearing and avoiding situations with ambiguous
  outcomes
• preferring the occurrence of a negative outcome
  to its possibility
• Only situations that are perfectly controlled are
  safe
• But, uncertainty is certainly inevitable!
• Anxiety about uncertainty is closely linked to
  fears about unpredictability uncontrollability
  and positive beliefs about worry
• If I am in control and know what will happen,
• then I can prevent negative outcomes
• worry helps me do this

69
INTOLERANCE OF UNCERTAINTY AND WORRY - DUGAS ET
AL. (1997)
CORRELATION WITH PSWQ UNIQUE VARIANCE EXPLAINED
BAI .54 25.2
BDI .53 8.0
PROB SOLV SKILLS .16 0.6
INTOL. OF UNCERT. .70 16.3
70
TE2. Confirmation of Beliefs about the Self

• Anxiety is also experienced when there is the
  potential for negative core beliefs to be
  confirmed
• e.g., Doing an exam will be anxiety-provoking if
  you believe it may confirm beliefs about
  inadequacy
• In response to the anxiety, clients use safety
  strategies, like perfectionism
• e.g., Engaging in non-stop studying to prevent
  potential failure
• e.g., Last minute studying allows a more
  palatable excuse should failure occur
• Potential confirmation of beliefs triggers
  anxiety
• Perceived confirmation of beliefs triggers low
  mood

71
TE3. Meta-beliefs about Affect

• Negative affect is perceived as threatening in
  GAD because it is experienced as overwhelming and
  distressing
• The experience of intense affect triggers
  attempts at avoidance or neutralizing
• Emotions that may be perceived as threatening
• Fear and Anxiety
• Anger
• Depression
• Positive affect?

72
TE4. Meta-beliefs about Coping

• The perceived consequences of not coping with
  negative outcomes is also seen as threatening
• For example, If I cant cope with the feared
  event, does that mean
• I am a failure?
• I am irresponsible?
• Its my fault?
• I am a bad person?
• I cant tolerate these feelings of guilt
• People with GAD hold rigid standards about coping
  they should cope perfectly, without any
  distress

73
TE5. Meta-beliefs About Cognition - Worry is
Threatening

• People with GAD hold strong beliefs that the
  process of worrying is dangerous to them (e.g.,
  Wells, 1997)
• If you believe that worry is harmful then you
  will probably spend a lot of time monitoring your
  thoughts, trying not to worry, and engaging in a
  range of associated safety strategies (e.g.,
  checking physical symptoms thought suppression)

74
Examples of Negative Meta-worries

• My worrying is uncontrollable
• Worrying is harmful to me
• I could go crazy from worrying
• My worries will take over and control me
• I could get into a state of worrying and then
  never be able to stop
• If I worry too much I could lose control
• Worrying makes me physically sick and puts stress
  on my body
• If I dont control my worry then it will control
  me
• If I worry it means I am a weak person
• People will respect me less if they find out
  about my worry
• My worry is harmful to others (eg family members)

75
Avoidance Proactive Safety Strategies Trying
to Feel Safe and In Control

• The experience of intense negative affect
  triggers the use of behavioural, cognitive and
  emotional safety strategies
• Perfectionistic behaviour may be triggered if not
  doing well on a task confirms beliefs about
  inadequacy
• Engaging in frequent attempts to suppress worries
  may be triggered by beliefs that worry is harmful
• People with GAD use a large array of safety
  strategies to try and control potential negative
  outcomes and so they can feel safe

76
Some Safety Strategies
Behavioural Reassurance seeking Controlling
others, situations, feelings Perfectionism Over-re
sponsibility Busyness Procrastination Avoiding
uncertainty Avoiding triggers
Cognitive Thought suppression Shifting, narrowing
attention Distraction Checking symptoms Positive
meta-beliefs about worry?? Rumination??
Emotional Repression Dissociation Numbing Emotiona
l blunting
77
Effects of Using Safety Strategies

• Safety strategies provide some relief from
  anxiety in the short-term by exerting a dampening
  effect on anxiety
• But, safety strategies reinforce negative
  underlying schema and threat expectancies in the
  long term by
• Preventing disconfirmation of beliefs about
  threat
• Providing some confirmation for beliefs about
  threat

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TREATING GAD
79
Standard CBT Components

• Psychoeducation about anxiety
• Detecting triggers and early warning signs
• Implementing alternative coping strategies
• Teaching realistic thinking skills
• Teaching relaxation skills
• Teaching problem solving/stress-reduction skills
• Graded exposure (e.g., to worry triggers)
• Exposure to worry
• Worry time

80
Treatment Reality

• Research has shown that CBT is effective at
  reducing anxiety for sufferers. But the outcome
  data is not so impressive and we can still do a
  lot better
• After 16 years of concerted effort, applications
  of behavioral and cognitive therapy techniques
  for treating this anxiety disorder continue to
  fail to bring about 50 of our clients back to
  within normal degrees of anxiety (Borkovec,
  2002, p.76)

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What Should We Address in Therapy?

• Myriad of threat expectancies
• Underlying negative schemas
• The multitude of safety strategies that are in
  place to neutralize or avoid potential threat
• Particularly important to address the avoidance
  of intense affect and to facilitate the
  completion of emotional processing

82
Acceptance Mindfulness-based Approaches

• Premise We compound our suffering by trying to
  avoid it
• Mindfulness is a strategy for gradually turning
  the clients attention toward the fear (external
  and/or internal) as it is happening and exploring
  it in detail with increasing degrees of
  acceptance
• Gradual shift in clients relationship to anxiety
  from avoidance to tolerance to acceptance
• Mindfulness is an awareness of, rather than
  thinking about, mental events - implying
  acceptance

83
Acceptance Mindfulness-based Approaches

• The overarching goal is to reorient clients away
  from maladaptive attempts to alter their thoughts
  and feelings, and toward making positive,
  sustained behavioural change that is consistent
  with ones values goals - essentially to live
  better rather than to think and feel better

84
Current Questions ???

• Control approach vs. acceptance approach ?
• Can we integrate mindfulness/acceptance with CBT
  ???

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My Contact Details

• Jonathan Gaston
• Director Emotional Health Clinic
• Centre for Emotional Helath
• Phone [phone]
• Fax [phone]
• Mobile [phone]
• Email jgaston_at_psy.mq.edu.au
• Office Room 605, Building C3B