1. Behavioral Interventions for Anxiety
Disorders
Dr. Maite P. Mena

2. Cognitive Behavior Therapy (CBT) has been found to
be an efficacious treatment for anxiety disorders
including:
 GAD
 PTSD
 OCD

3. Beck’s negative cognitive triad
Negative view of self
I’m no good
I’m useless
I’m inadequate
Negative view of the Negative view of the
world future
My problems are insurmountable It will always be this way
People are cruel I will never get better
Everything is very difficult Things will never work out for me

4. CBT is based on the cognitive model, which states that
people’s emotions, behaviors, and physical reactions
are influenced by how they perceive events. The
principles of CBT are:
1)Formulate problem in cognitive terms:
-What aspects of client’s current thinking acts to
maintain problematic emotions and behaviors?
-Therapist might also be concerned with precipitating
factors (context)- what environmental events might
have influenced perceptions
-Therapist would also be interested in developing
hypotheses about key developmental events and
enduring patterns of interpreting these events.

5. CBT Principles
2) Therapy requires a good therapeutic alliance-
warmth, caring, genuine regard
 Listening closely
 Empathizing
 Accurately summarize thoughts and
emotions

6. CBT Principles
3) Collaboration and active participation-
-Encourage client to view therapy as
teamwork
-Assign work between sessions
-Over time, give client more responsibility to
direct session.

7. CBT Principles
4) Cognitive Therapy is goal-oriented and problem-
focused
 Client encouraged in initial session to develop a
problem list
 Set specific goals of a behavioral nature-lonely-
develop new friendships-develop plan, set HW
 Identify thoughts interfering with goals

8. Principles-CBT
5) Present focused- here-and-now emphasis first
(want to reduce symptom stress).
Attention shifts to past when: a) client expresses
strong desire, b) work on present problems
produces little change in
cognitions, emotions, behaviors, c) important
dysfunctional ideas developed in the past (If I
always do well, I am ok, if I don’t do well I am not
ok)

9. Principles-CBT
6) Cognitive therapists aim to educate the person
so that they can be their own therapist (self-help)
using the techniques learned in therapy.
7) Therapy is intended to be time-limited (4-14
sessions) however this is not always possible.
8) CBT is structured.

10. CBT-Principles
9) Cognitive therapy teaches clients to identify,
evaluate, and respond to their dysfunctional thoughts
and beliefs
 The most basic question is to ask, ―What was going
through your mind when _____?‖
 Then evaluate the validity of the thought via Socratic
Questioning-Where is it written that what you told
yourself is true, and even if it were true, is it really as
bad as you tell yourself?
 CBT uses collaborative empiricism- helping determine
accuracy of a thought.

11. CBT-Principles
10) Cognitive therapy use a variety of techniques
to change thinking, mood and behavior.
Emphasis in treatment also depends on disorder
client is presenting with.

12. CBT
 Therapist enters ―collaborative‖ relationship with
client.
 The therapy is very structured and the session
follows an agenda starting with review of
homework and ending with a summary.

13. CBT
 Therapist needs to focus on systematic errors
in reasoning and restructure.
 Negative automatic thoughts disrupt one’s
mood. Leads to spiraling down.
 Distorted reasoning based on systematic
logical errors.
 Therapy is an active process (eliciting self-
talk/interpretations, gathering evidence
against interpretation, setting up homework)

14. Automatic Thoughts
 A spontaneously arising verbal or visual content
of consciousness with symbolic representation.
 Automatic thoughts are brief and patients are
often more aware of the emotion they feel as a
result of their thoughts than of the thoughts
themselves.

15. Negative Automatic Thoughts
 Short, specific thoughts which often do not
occur in sentences, but may consist of a few
key words, images or memories
 Spontaneous and often extremely rapid
 Not the result of deliberation or reasoning
 Associated with negative emotional reactions
 Generally appear reasonable at the time but
usually involve more distortion of reality than
other types of thinking

16. Identifying and challenging cognitive
distortions
 First step is to identify negative beliefs.
 Write descriptions of situations where they
experienced disturbing emotions.
 Document their emotions as these will give a clue
as to the likely cognitive distortion underlying their
difficult emotions.
 Write down negative thoughts.

17. Environment
Affect
Behaviour Symptoms
Negative
Automatic Thought
Intermediate Belief
Core belief

18. Identifying and Categorizing Core
Beliefs (the therapist)
 Mentally hypothesize where core belief specific
automatic thoughts came from
 Specify the core belief
 Present hypothesis about the core belief to the
patient
 Educate patient about core beliefs in general and
about their core beliefs
 Help patient specify and strengthen a new more
adaptive core belief
 Begin to evaluate and modify negative core
beliefs with patient

19. Cognitive Restructuring
 CBT holds that most of our emotions and behaviors are the
result of what we think or believe about ourselves, other people,
and the world.
 These cognitions shape how we interpret and evaluate what
happens to us, influence how we feel about it, and provide a
guide to how we should respond.
 Sometimes our interpretations, evaluations, and underlying
beliefs thoughts contain distortions, errors, or biases, or are not
very useful or helpful.
 Cognitive restructuring is a set of techniques for becoming more
aware of our thoughts and for modifying them when they are
distorted or are not useful. This approach does not involve
distorting reality in a positive direction or attempting to believe
the unbelievable. Rather, it uses reason and evidence to replace
distorted thought patterns with more accurate, believable, and
functional ones.

20.  The term ―cognitive distortion‖ refers to errors in
thinking or patterns of thought that are biased in
some way. They may include: (A) interpretations
that are not very accurate and which selectively
filter the available evidence, (B) evaluations that
are harsh and unfair, and/or (C) expectations for
oneself and for others that are rigid and
unreasonable. The more a person’s thinking is
characterized by these distortions, the more they
are likely to experience disturbing emotions and
to engage in maladaptive behavior.

21. Some examples of common patterns of cognitive distortions
are:
 All-or-nothing thinking: Looking at things in absolute, black-and-white
categories, instead of on a continuum. For example, if something is less than
perfect, one sees it as a total failure.
 Overgeneralization: Viewing a negative event as a part of a never-ending pattern
of negativity while ignoring evidence to the contrary. Using words such as
never, always, all, every, none, no one, nobody, or everyone.
 Mental filter: Focusing on a single negative detail and dwelling it on it exclusively
until one’s vision of reality becomes darkened.
 Magnification or minimization (e.g., magnifying the negative and minimizing the
positive): Exaggerating the importance of one’s problems and shortcomings. A
form of this is called ―catastrophizing‖ in which one tells oneself that an
undesirable situation is unbearable, when it is really just uncomfortable or
inconvenient.

22.  Mind reading: Concluding what someone is thinking without any evidence, not
considering other possibilities, and making no effort to check it out.
 Emotional reasoning: Assuming that one’s negative emotions necessarily reflect
the way things really are (e.g., ―Because I feel it, it must be true.‖ ―I feel stupid,
therefore I am stupid‖).
 Rigid rules (perfectionism). Having a precise, fixed idea of how oneself or others
should behave, and overestimating how bad it is when these expectations are
not met. Often phrased as "should" or ―must‖ statements.
 Unfair judgments: Holding oneself personally responsible for events that aren't
(or aren’t entirely) under one’s control, or blaming other people and overlooking
ways in which one might have also contributed to the problem.

23. In CBT:
 The therapist guides the client through the process of becoming
more aware of what they are telling themselves and helps them
to evaluate, and when appropriate, to modify their own thinking.
 The therapist teaches the client a process that will help them
distinguish distorted thinking from more accurate and useful
thinking.
 The therapist does not assume that the client’s thoughts are
distorted and instead attempts to guide the client with questions
that encourage the client to make their own discoveries.
 Clients are also encouraged to practice this process on their own
between sessions (homework).

24. CBT Homework
 Homework is integral to CBT and the goal is to
extend the opportunities for cognitive and
behavioral change throughout the patient’s week.
 Tailor the assignment to the individual
 Provide sound rationale
 Uncover potential obstacles
 Modify relevant beliefs

25. Other behavioral interventions to
treat Anxiety Disorders
 Exposure Therapy, Systematic desensitization
 Relaxation

26. Systematic desensitization
 Developed by Joseph Wolpe in 1950s
 Patient creates hierarchy of 20-30 items of ascending
fearfulness
 Deep muscle relaxation practiced while imagining each
scene repeatedly until it could be imagined without anxiety.
 Pairing of opposite emotional experiences (relaxation with
anxiety-provoking stimuli) termed reciprocal inhibition.

27. Systematic Desensitization
 Systematic desensitization is a therapeutic
intervention that reduces the learned link between
anxiety and objects or situations that are typically
fear-producing.
 The aim of systematic desensitization is to reduce or
eliminate fears or phobias that sufferers find are
distressing or that impair their ability to manage daily
life.
 By substituting a new response to a feared situation,
a trained contradictory response of relaxation which is
irreconcilable with an anxious response — phobic
reactions are diminished or eradicated.

28. Exposure therapy
 Developed by Marks, Gelder & Rachman in the
late 60s and 70s.
 Good results using graded exposure in vivo for
phobias and OCD.
 Flooding is exposure to feared stimulus at
maximal intensity until anxiety habituates – rapid
& effective but very distressing for the patient.

29. Exposure Therapy
 Exposure is an important behavioral technique in the
treatment of anxiety disorders.
 Assumption is that anxiety is maintained by avoidance
of the feared stimuli.
Exposure to the feared stimuli:
 Challenges the belief that there are negative
consequences by coming into contact with the stimuli
 Allows physiological ―habituation.‖

30. Exposure to what?
 Posttraumatic Stress Disorder- expose to traumatic
st
memories (1 ) and avoided places, people, activities
nd
(2 ).
 Obsessive Compulsive Disorder- expose to obsessive
thoughts and triggers of compulsions with avoidance
of compulsive behavior (response prevention).
 Generalized Anxiety Disorder- expose to worries

31. Exposure therapy
 Graded Hierarchy – patient controlled and directed
 ―Anxiety is unpleasant but does no harm.‖
 As real as possible (imagination < in vivo) , to
produce the greatest level of discomfort and anxiety
that the patient is willing to experience
 Without internal or external distraction
 Until anxiety goes away or is reduced by at least 50%.
 ―Anxiety eventually reduces.‖
 As frequent as possible
 ―practice makes perfect.‖

32. Types of Exposure
 In session exposure (imagined)
 In vivo exposure

33. In session exposure
 Patients imagine themselves coming into contact
with the feared stimuli.
 Described coming into contact with the feared
stimuli onto a tape recorder with their eyes
closed.
 Re-expose themselves to this recording.

34. In session exposure is used when:
 Exposure to live situations is too anxiety
generating for the patient to tolerate.
 Live exposure is impractical.
 Exposure is not immediately available.
 The queues are not external but are internal e.g.
memories.

35. In vivo exposure:
 This is the best form of exposure and should be used
wherever possible.
 Patients can normally initiate their own exposure
 Initially this may be modelled by the therapist to assist
this process.
 Once initiated in a clinical setting the patient is
encouraged to repeat this as frequently as possible
outside the therapy sessions.

36. Steps in conducting exposure
 Preparation.
 Creation of exposure hierarchy.
 Initial exposure.
 Repeated exposure.

37. Preparation for conducting exposure
 Explain treatment rationale.
 Explore advantages and perceived
disadvantages of doing exposure.
 Obtain, inform, consent and commitment to
carrying out exposure.
 Explain that:
 Anxiety is unpleasant and does no harm
 Anxiety eventually reduces
 Practice makes perfect

38. Creation of exposure hierarchy
 The patient should describe all cues that evoke
anxiety (alternatively describe the things they
avoid) and create a list
 Rate each item on a 0-100% scale
 0 being no discomfort/anxiety
 100 being maximum discomfort/anxiety
 Can rate in imaginable contact
 Use rating to rank list

39. Initial Exposure
 Graded exposure involves graduated exposure
beginning with the item that produces least
discomfort/anxiety and working up the scale.
 Habituation can take hours and sessions should be
structured accordingly (initial exposure continued
while another patient is being seen before the session
may be continued).
 The patient should rate their anxiety/discomfort on a
0-100 scale every five minutes and exposure
continued until anxiety has reduced by at least 50%.

40. Repeated Exposure
 This should be continued on at least a daily basis
 Record each event as exposure is carried out.
 The patient moves up the hierarchy as they feel
able.

41. Relaxation techniques:
Goals in relaxation
 A coping mechanism to help patients gain a
sense of mastery over their internal world
 Aim is to facilitate engagement with activities of
everyday living and exposure tasks.
 Not an intrinsic therapeutic activity.

42. Different types of relaxation
Progressive muscle Breathing relaxation.
relaxation. Cue controlled relaxation.
12 muscle group relaxation. Holding the breath.
8 muscle group relaxation. Rhythmic breathing.
4 muscle group relaxation. Counting breaths.
Release only relaxation.

43. Relaxation method
 Take a comfortable position
 Using fixed narrative
 Encouraged to breath gently
 Tense the area to the count of three breaths and then
release slowly to the count of five
 Pause for 15 to 20 seconds
 Progressing to the next muscle group.
 At end counting down five to one visualising
relaxation.
 Repeated using tape recorder.

44. 12 muscle group relaxation
These are:  Shoulders.
 Lower arms.  Back of the neck.
 Upper arms.  Lips.
 Lower legs.  Eyes.
 Thighs.  Eye brows.
 Stomach.  Upper forehead and
 Upper chest and back. scalp.

45. 8 muscle group relaxation
1. Whole arms.
2. Whole legs.
3. Stomach.
4. Upper chest and back.
5. Shoulders.
6. Back of the neck.
7. Face.
8. Forehead and scalp.

46. 4 muscle group relaxation
1. Whole arms.
2. Upper chest and back.
3. Shoulders and neck.
4. Face.

47. Relaxation key points
 Focus on the physical sensation of tension and to
gain mastery over this.
 Use diaphragmatic breathing rather than light
chest breathing which can lead to hyper-
ventilation.
 These breaths can be timed to the count of three.