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Therapy: Anxiety Management & Relaxation


Therapy: Anxiety Management & Relaxation Psychological techniques for managing anxiety Frank McDonald Consultation-Liaison Psychologist The Townsville Hospital – PowerPoint PPT presentation

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Title: Therapy: Anxiety Management & Relaxation

Therapy Anxiety Management Relaxation
  • Psychological techniques
  • for managing anxiety
  • Frank McDonald
  • Consultation-Liaison Psychologist
  • The Townsville Hospital
  • Queensland
  • Australia

Edvard Munch, 1896 - Anxiety
  • Aim Objective
  • General comments on psychological management
  • General considerations in medically managing
  • Psychological strategies for mx anxiety brief
  • Class exercise on instant strategies
  • Common anxiety disorders what technique goes
    best with what condition?
  • Evidence for psychological treatments
  • Resources for practical applications
  • Optional self-test
  • References

Aim Objective
  • Aim
  • To briefly survey some psychological strategies
    for mx of anxiety (Some easily acquired or a
    natural part of medical roles that youll develop
    soon, if havent already. Others need further
    training or referring on)
  • Objective
  • Students will be more aware of psychological
    methods of managing common anxiety presentations

General comments on psychological mx
  • Anxiety is a normal emotion in response to threat
    a powerful motivator
  • Mild to moderate levels of anxiety improve the
    ability to cope, reactions become faster,
    understanding is better responses are more
  • On balance, acute moderate fear/anxiety a good
  • However, chronic high levels of anxiety reduce
    capacity to plan, make accurate judgments, carry
    out skilled tasks, comprehend useful
    information they can paralyze thinking action

General comments on psychological mx
  • Psychological treatments (especially
    cognitive-behavioural therapies) can help restore
    mental health of anxious people overcome
    debilitating effects of excessive anxiety  
  • Anxiety disorders are manageable, given skilful
    practitioner hard-working patient
  • However, chronic diffuse disorders like GAD are
    more difficult to treat successfully

General comments on psychological mx
  • Two main psychological interventions for anxiety
    disorders are the cognitive the behavioural
  • 1. Cognitive Therapy (termed
    Cognitive-Behaviour Therapy or CBT when, as is
    usual, combined with behavioural techniques)
    Cognitivists To feel differently, think
    differently. Distorted beliefs other cognitive
    processes, like attention bias, contribute to
    psychopathology. Change internal processing of
  • Therapist pt challenge re-structure
    cognitive distortions other unhelpful
    cognitions (specific thoughts, schema,
    spontaneous images, fantasies etc.) and/or modify
    attention e.g. via meditation

General comments on psychological mx
  • 2. Behaviour Therapy
  • Behaviourists To feel differently, act
    differently. Change behaviour or manipulate
  • - They apply principles of 3 main theories of
  • Classical conditioning (Ivan Pavlov) learning
    by association
  • Relaxation exposure (systematic
    desensitisation, flooding response prevention)
    are behavioural anxiety mx methods based on
    classical conditioning

General comments on psychological mx
  • Operant conditioning (B F Skinner) learning by
    operating on the environment its subsequent
  • No anxiety conditions treated by this alone. But
    rewards (positive reinforcement) ending
    aversive experiences (negative reinforcement)
    help other approaches
  • E.g. more social assertion (less anxious
    withdrawal) brings pleasing responses from others
    reduces loneliness. Increases chances of less
    anxious behaviour

General comments on psychological mx
  • Social (or observational) learning (Albert
  • Learning by experiences in social relationships
    via negative positive modelling
  • Observing respected or significant others,
    whether they are rewarded or punished, sets up
    expectations in observer, results in behaviour
  • Bridges cognitive behavioural theories.
    Learning can occur faster - by observation alone
    without changes in behaviour first, nor direct
    modification of cognitions

General considerations in medically managing
  • Treating anxiety part of mx of most medical
    conditions. Improves compliance and Q o L,
    reduces disability, decreases service reliance,
    improves outcomes e.g. less anxious surgical pts
    recover significantly sooner. Treating anxiety
    disorders, when associated with other psych
    disorders (p.d., depression, substance use),
    reduces suicide risk3
  • Not always possible to engage mental health
    professional, so treating anxiety a core skill
    for doctors
  • So, what can you do immediately to help (i.e.
    without advanced training in CBT etc)?

General considerations in medically managing
  • Giving information, tailored to individual
    wishes, can go a long way to help most anxious
  • Specifically, education about the nature of
    anxiety its effects e.g. does not cause heart
    attacks in otherwise healthy pts4
  • Counselling to help pt re-evaluate cause of
    anxiety symptoms, linking them to past or current
    psychosocial stresses - not some mysterious
  • Education to discourage avoidance/maintain
    routine activities despite anxiety

General considerations in medically managing
  • Anxiety associated with poor communication. Use
    of open questions, discussing psychological
    issues, empathising, summarising while avoiding
    simple reassurance, advice mode leading
    questions associated with greater disclosure
    enduring change in anxious pts5
  • Preparation for unpleasant procedures can give
    pts opportunity to plan short-term coping
  • Exercise regimens (e.g. 10-15 week aerobic
    course)6 can burn off hormones associated with
    anxiety for several hours
  • Practical help/referral e.g. budgeting,
    childcare, housing
  • As well, you can apply some of the following
    techniques. Others need further training or
    referring on

Some psychological strategies for managing
anxiety an overview
  • Relaxation techniques (for chronic autonomic
    arousal, on edge uptight, even when not
    exposed to fear)
  • Breathing retraining/ respiratory feedback for
    spontaneous cued panics
  • Visual imagery like safe, content place
  • Progressive (deep) muscle relaxation/isometric
    relaxation/ (better if combined with other
    techniques practiced regularly)
  • Auto-suggestion/self-hypnosis
  • Flooding (face your fear principle intense,
    no escape until settled, can be quicker, rarely
  • Graded exposure (face your fear principle
    gradual, based on 0-10 or 100 pt Subjective Units
    of Disturbance Scale or SUDS ratings of various

Some psychological strategies for managing
anxiety an overview
  • Graded exposure (contd)
  • Identify specific goals and break them into
    smaller, manageable steps
  • Initially, learn to master situations that cause
    mild anxiety
  • Progressively master situations that are
    associated with greater anxiety
  • Confront fears regularly frequently
  • Emphasise reasonable habituation to anxiety (say
    20-30/100 on subjective scale) for each exposure
    hierarchy item before progressing. Pt. doesnt
    have to be perfectly relaxed manageable is
  • Can be therapist-assisted or self-directed

Some psychological strategies for managing
anxiety an overview
  • Problem-solving (brainstorming instead of what
  • Thought stopping (Stop! Technique. Disrupts
    ruminations/worry, combine w. other techniques)
  • Cognitive restructuring (challenging modifying
    distressing thoughts, distortions, schemas,
    images. Works much better if pt does homework
    diaries etc)
  • Distraction (e.g. how re-decorate room?, acute
    anxiety e.g. of GAD not PTSD, phobias, owise can
    interfere with exposure/need to face fears)
  • Coping statements (flashcards of anti-worry
  • Worry-time/worry place (modifies cues)
  • Meditation (trains switching off of
    catastrophic thinking)
  • Assertiveness Training/ Social Skills Training
    (counters social anxieties)

Some psychological strategies for managing
anxiety Class Exercise
  • Class Exercise You have a pt suffering
    in-session anxiety. You ask Which symptoms are
    most distressing? to guide your intervention
  • Physiologic symptoms (such as palpitations,
    tremors, tachypnea)?
  • Affective symptoms (unpleasant feelings, anxious
  • Cognitive symptoms (racing thoughts, poor
    concentration, thoughts of impending doom, loss
    of control fears)?
  • You start with one or two coping skills that
    are not too complex and can be applied
  • If chief symptoms were physiologic and /or
    affective, what might you suggest?
  • If chief symptoms were cognitive, what might you
  • Script actual instructions. You may want to begin
    and end intervention with a SUDS. Why?

Common Anxiety Disorders When how to apply
  • Panic Disorder with Agoraphobia
  • Features
  • Sudden attacks of fear or anxiety in situations
    of little danger
  • Symptoms of the "flight or fight" response,
    complicated by hyperventilation and worsened by
    the fear of collapse or death
  • Avoidance, for fear of panic, of situations from
    which escape is not possible or help is not
    available, typically public transport, travelling
    alone, crowded or lonely places

Common Anxiety Disorders When how to apply
  • Psychological management PDA
  • Education about nature of disorder
  • Central feature of all anxiety disorders is that
    pts complain of physical symptoms of "flight or
    fight" response - rapid heart rate, need to
    overbreathe, tremor shaking, nausea, sweating
    focusing of attention (though men women have
    different hormonal responses that produce
    behavioural nuances)
  • Education about meaning of these symptoms is key
    part of treatment (i.e. that they do not indicate
    physical illness, that they can be understood

Common Anxiety Disorders When how to apply
  • Psychological management PDA
  • Regularising breathing rate slow steady 6
    second cycle technique
  • Graded exposure to feared situations. See next

Common Anxiety Disorders When how to apply
  • Example of a graded exposure hierarchy
  • for Agoraphobic or Social Phobic pt
  • Goal To travel alone by bus to the city and back
  • 1. Travelling one stop, quiet time of day
    (anxiety level 4/10)
  • 2. Travelling two stops, quiet time of day
  • 3. Travelling two stops, rush hour (anxiety level
  • 4. Travelling five stops, quiet time of day
  • 5. Travelling five stops, rush hour (anxiety
    level 8/10)
  • 6. Travelling all the way, quiet time of day
  • 7. Travelling all the way, rush hour (anxiety
    level 10/10)

Common Anxiety Disorders When how to apply
  • Generalised Anxiety Disorder
  • Features
  • Excessive anxiety or worry, occurring on most
    days for more than 6 months
  • The worry is out of proportion to the event,
    pervasive and excessive, difficult to control
  • Accompanied by muscle tension, hyperarousal and
    symptoms of the "flight or fight" response

Common Anxiety Disorders When how to apply
  • Psychological management GAD
  • Education about nature of disorder
  • Structured problem solving
  • (See later slide)
  • Graded exposure to difficult situations (See
    earlier slide)
  • Cognitive-behaviour therapy e.g. written
    disputations, worry-time/worry-place. Discuss
  • Support (guidance, advice/corrective info,
    development of coping strategies)
  • Counselling
  • Stress management (relaxation, meditation,
    exercise regimens that improve stress recovery
    like cross-stressing7)

Common Anxiety Disorders When how to apply
  • Obsessive-Compulsive Disorder
  • Features
  • Obsessions are thoughts, images or impulses that
    occur repeatedly, are intrusive distressing
    can't be supressed or neutralised. Not
    ego-syntonic like worry is
  • Compulsions are repetitive behaviours used to
    control or neutralise the obsessions and prevent
    the harm reduce the anxiety, but which are
    excessive disabling

Does anal-retentive have a hyphen?
This perfectionism of yours just isnt good
Common Anxiety Disorders When how to apply
  • Psychological management OCD
  • Education about the nature of the disorder
  • Exposure Response prevention / help to resist
    carrying out compulsions
  • Discuss case example of pt who has to
    continuously check kettle is not setting fire to
  • Relies on classical conditioning principle of
    extinction. See graph

Common Anxiety Disorders When how to apply
  • Social Phobia
  • Features
  • Excessive unreasonable fears of being the
    centre of attention in case of negative
    evaluation because of looking anxious or doing
    something embarrassing
  • Situations that could lead to scrutiny or
    evaluation (social functions, being in a crowd,
    speaking to others) are avoided or endured with
    intense anxiety

Common Anxiety Disorders When how to apply
  • Psychological management
  • Social Phobia
  • Education about nature of disorder
  • Cognitive-behavioural strategies
  • e.g. graded exposure therapy,
  • rational disputation/Socratic questioning
    e.g. evidence to support your idea?, social
    skills training

Common Anxiety Disorders When how to apply
  • Post-Traumatic Stress Disorder
  • Features
  • Exposure to extreme trauma e.g. that threatens
  • Recurring images of the trauma
  • Distress triggered by similar events persistent
  • Avoidance of cues/reminders of trauma

Common Anxiety Disorders When how to apply
  • Psychological management PTSD
  • Education about the nature of the disorder
  • Exposure to the traumatic material
  • - via graded exposure to cues (central
  • - allows activation of fear, confronting it
    thereby extinguishing it
  • Cognitive-behavioural strategies e.g. challenging
    modifying their disruptive thoughts how much
    time did you really have to try and save the
    other person? refer to time-distortion in
    recalling trauma, as discussed in education part
    thought stopping, physical relaxation, role
    playing etc
  • Treatment of co-morbid disorders, especially
    depression, substance use

Common Anxiety Disorders When how to apply
  • Specific Phobia
  • Features
  • Excessive fear of a specific object or situation
  • e.g. flying, heights, animals, sight of
    blood, medical procedures such as injections
  • Exposure to the phobic stimulus almost invariably
    provokes an immediate anxiety response e.g. Panic
  • Person (many have a biological vulnerability)
    realises the fear is excessive or unreasonable

Common Anxiety Disorders When how to apply
  • Psychological management Specific Phobia
  • Education about nature of disorder
  • Graded exposure to difficult situations
  • Progressive muscle relaxation or other relaxation
    to counter autonomic arousal
  • Applied muscle tension in needle phobics to
    counter vasovagal/ fainting responses8)

Common Anxiety Disorders When how to apply
  • Structured problem solving
  • Best antidote to catastrophising/ thinking the
    worst seen in worriers Very few, if any,
    worriers engage in problem solving
  • Do examples with pt during appts until manage on
  • Give pt copies of work sheets for home practice.)
  • Step 1 What is the problem/goal? Think about the
    problem/goal carefully, ask yourself questions.
    Then write down exactly what the problem/goal is.
  • Step 2 List all possible solutions Put down all
    ideas, even bad ones. List the solutions without
    evaluation at this stage. 1.
  • 2. _______________________________________
  • 3. _______________________________________
  • 4. _______________________________________
  • 5. _______________________________________
  • 6. _______________________________________

Common Anxiety Disorders When how to apply
  • Step 3 Assess each possible solution Quickly go
    down the list of possible solutions and assess
    the main advantages and disadvantages of each
  • Step 4 Choose the "best" or most practical
    solution Choose the solution that can be carried
    out most easily to solve (or to begin to solve)
    the problem.

Common Anxiety Disorders When how to apply
  • Step 5 Plan how to carry out the best
    solution List the resources needed and the major
    pitfalls to overcome. Practise difficult steps,
    make notes of information needed.
  • Step 1. ___________________________________ Step
    2. ___________________________________ Step 3.
    ___________________________________ Step 4.

Common Anxiety Disorders When how to apply
  • Step 6 Review progress and pat yourself on the
    back for any progress Focus on achievement
    first. Identify what has been achieved, then what
    still needs to be achieved. Go through steps 1 to
    6 again in the light of what has been achieved or
    learned. What has been achieved?
  • What still needs to be done?

Collaborative Management
  • Anxiety Disorders usually treated with
    counselling or psychotherapy or pharmacotherapy,
    as mono-therapies. No empirical support for
    combining (unlike depression)9,10. Bad news for
    pt who responds to neither rx
  • Milder forms may be effectively treated with
    cognitive or behaviour therapy alone, but more
    severe persistent symptoms may need to start
    with pharmacotherapy. Sequential rather than
    concurrent therapies may be more successful.
    Currently under study11

Evidence for Psychological treatments of anxiety
  • Evidence suggests that CBT treatment packages
    Behavioural treatments (especially
    exposurebased) are among the most effective for
    anxiety disorders12, especially those
    Behavioural treatments that target avoidance
  • Avoidance rewards anxiety with relief prevents
    behavioural experiments/testing of
    unreasonableness of fear
  • Level of evidence for CBT Exposure-based
    approaches can reach Level 2 on 5 point scales (2
    RCTs w/out double blind placebo control)

Evidence for Psychological treatments of anxiety
  • Limited evidence base for effectiveness of
    physical relaxation therapies, as sole rx, in
    relieving anxiety13,14
  • However, can be used as an attention diversion
    strategy e.g. to aid sleep onset for worriers
  • With practice may help chronic tension levels
    causing muscle aches insomnia

Evidence for Psychological treatments of anxiety
  • Impossible to provide Level 1, or double blind,
    psychological interventions in which neither pt
    nor therapist knows which intervention delivered
  • Arguable that best practice should also include
    Level 5 evidence i.e. based on accumulated
    clinical wisdom of experienced experts15.
  • Even arguments against evidence-based principles
    in psychiatry, because its diagnostics are based
    on consensus subtle symptom shifts, not
    experimentally derived knowledge16

Evidence for Psychological treatments of anxiety
  • In spite of evidence that CBT works, singularly
    effective ingredients not been identified for the
    anxiety disorders they improve. Its the
    package that works17
  • Clark18 narrows down six active ingredients in
    Cognitive therapy that, combined, prove highly
    effective in Panic Disorder, Hypochondriasis,
    Social Phobia PTSD ( possibly others)
  • psycho-education
  • verbal discussion techniques
  • imagery modification
  • attentional manipulations
  • exposure to feared stimuli
  • behavioural experiments, such as manipulation of
    safety behaviours (e.g. avoidances)

Evidence for Psychological treatments of anxiety
  • Other factors such as unconscious processing in
    everyday thinking18 or the quality of the
    therapeutic relationship19 have also been shown
    to influence outcomes in Cognitive
    exposure-based therapies
  • e.g. warm therapists get better results than
    cold therapists, even in mechanical,
    straight-forward desensitisation procedures

  • My web page
  • (Copies of stress manuals, anxiety
    management h/os, Behavioural and Auto-suggestion
    strategies for sleep, CBT for Psych Registrars
    presentation etc)
  • Centre for Clinical Resources http//www.cci.hea Lots of practical
    resources for pts and professionals alike
    covering a range of common psychological issues.
    Concise but comprehensive, clearly and
    attractively presented.
  • Australian Govt Health Insite http//www.healthi

  • Causes Treatments of Anxiety Disorders
    Clinical Research Unit for Anxiety Disorders
    (CRUfAD) http//
    It offers information so that some people can
    help themselves, it offers comprehensive
    information so that doctors can know the right
    treatment, and it offers information on the
    latest in our research. A related website offers very high quality pt
    therapy and education about the management of
    anxiety and depression and other disorders.
    Access to the Net-based self mx programs can be
    prescribed by a doctor or psychologist at a
    very moderate cost to pt or service
  • Treatment Manuals Textbooks from CRUfAD
  • Guidelines for Assessing Treating Anxiety
  • A little dated an NZ bias in places but
    very clear comprehensive guide for
    practitioners. Some useful pt appendices.
  • http//

Optional Self-test
  • A rather shy and introverted Engineering Student
    attends his GP surgery and says that he can't
    present his assignments in front of his seminar
    group. How can you help him?
  • Describe and discuss the various psychological
    treatments that are currently used in the
    treatment of Panic Disorder with Agoraphobia.
  • A 58 year old man attends medical outpatients for
    treatment following a recent myocardial
    infarction. He reports loss of interest and
    energy, has been unable to return to work, or to
    his previous interests. He complains of inability
    to concentrate, feeling on edge most of the
    time and has been unable to sleep. What anxiety
    management strategies might be part of the
    overall approach to this mans medical illness,
    anxiety and depression?
  • In a general practice you see many patients whose
    primary complaint is that they are "unable to
    sleep." Amongst the common reasons given for this
    presentation pts will say they cant switch
    off. So you suspect cognitive anxiety causes.
    What can you suggest in terms of self-management?

Optional Self-test
  • You are following up a 52 year old woman
    following the birth of her second child. She
    attends your general practice expressing worries
    about the failure of her child (now aged 6
    weeks) to feed properly, despite previous
    assurances that the child is well, and failure
    to detect any abnormality in the child. She
    appears tired and anxious, and states that she
    has been having problems with the behaviour of
    her other child now aged 2 years, with him
    becoming very demanding and irritable. She is
    married, works as a manager and has recently
    moved to the area from interstate. She is
    tearful, irritable, says that she is a "failure"
    as a mother, and complains of occasional feelings
    of severe panic that prevent her leaving the
    house alone.
  • Discuss how you would proceed with the
    assessment of this woman's complaints and
    presentation. Include a discussion of your
    immediate steps in management, including a
    justification for the steps you take.

Optional Self-test
  • Mrs G.R. is a 43 year old divorcee who has been
    treated for symptoms of anxiety for the past 3
    years with the benzodiazepine oxazepam. She
    comes to her GP complaining of an increase in her
    symptoms of anxiety and requests that her dose of
    oxazepam be raised from 30mg four times daily.
    There are no apparent stresses in her life. She
    adds that she is beginning to find it difficult
    to go to work.
  • She appears to be psychologically-minded
    and is willing to try other approaches after you
    suggest this. How would you manage this patient?