Anxiety Disorders: Summary

Anxiety Disorders: Introduction

First CBT treatment manual for anxiety disorders published in 1985, marking a significant milestone in the structured treatment of these conditions.
Anxiety is a normal, adaptive response to threat, preparing individuals for fight, flight, or freeze reactions essential for survival.
The anxiety response includes emotional (fear, worry), cognitive (attention bias, interpretation), physiological (increased heart rate, sweating), and behavioral systems (avoidance, escape). Each system interacts dynamically to influence the overall anxiety experience.
Anxiety becomes pathological when it's disproportionate to the actual threat, occurs in the absence of real danger, or significantly impairs functioning, or ones ability to cope with the threat is underestimated
Therapy aims to manage, not eliminate, anxiety by teaching coping strategies and modifying maladaptive thought patterns and behaviors.
Interpretations of events, rather than the events themselves, determine responses; the same situation can elicit different reactions based on individual perceptions and cognitive appraisals.

Characteristics of Anxiety and Anxiety Disorders

Normal anxiety is a linear process: Trigger → perceived threat → anxiety response → successful coping reaction → resolution of anxiety. The individual effectively deals with the threat, leading to a reduction in anxiety.
Anxiety disorders involve a circular process where maladaptive responses maintain or worsen anxiety. Avoidance, safety behaviors, and negative thought patterns perpetuate the anxiety cycle.
'Fear of fear' (anxiety sensitivity) is when the experience of anxiety becomes aversive and is avoided, leading to increased vigilance and hyper-awareness of bodily sensations.
Anxiety prepares the mind and body for danger by increasing alertness, focus, and physiological readiness; disorders exaggerate these symptoms, causing distress and impairment.

Symptoms of Anxiety

Cognitive: Threat overestimation, attentional bias towards threat, rumination, worry, catastrophic thinking, difficulty concentrating.
Physical: Increased heart rate, muscle tension, breathing rate, digestive changes, sweating, trembling, dizziness, fatigue.
Chronic anxiety can lead to sleep disorders and depression, exacerbating overall health and functioning.

DSM-V Diagnoses of Anxiety Disorders and Other Common Anxieties

Specific Phobia: Persistent, irrational fear of a specific object or situation (e.g., spiders, heights, flying).
Panic Disorder: Recurrent, unexpected panic attacks with symptoms like palpitations, breathlessness, dizziness, and fear of losing control.
Agoraphobia: Fear of being in places or situations where escape is difficult or help is unavailable in the event of a panic attack or other incapacitating symptoms.
Illness Anxiety Disorder (Hypochondriasis): Preoccupation with fears of having or acquiring a serious illness, despite medical reassurance.
Social Anxiety Disorder (Social Phobia): Fear of social or performance situations where one might be scrutinized by others, leading to embarrassment or humiliation.
Generalized Anxiety Disorder (GAD): Persistent, excessive worries and negative thoughts about various aspects of life, accompanied by physical symptoms like restlessness and muscle tension.
Obsessive-Compulsive Disorder (OCD): Recurrent, intrusive obsessions (thoughts, images, or urges) that cause anxiety, and compulsions (repetitive behaviors or mental acts) performed to reduce distress.
Acute Stress Disorder (ASD): Anxiety symptoms, dissociation, and other reactions occurring within one month after exposure to a traumatic event.
Post-Traumatic Stress Disorder (PTSD): Intrusive memories, avoidance of trauma-related stimuli, negative cognitions and mood, and hyperarousal lasting longer than one month after a threatening event.

Maintaining Processes

Anxiety disorders persist due to maintaining cycles involving cognitive, behavioral, and physiological factors.
Anxious individuals assume threat, leading to catastrophic conclusions or predictions about potential danger.
Protective behaviors (e.g., avoidance, reassurance-seeking) provide immediate relief but don't challenge the underlying beliefs about threat.
Anxiety disorders are perpetuated by reciprocal interactions between feelings, thoughts, and behaviors.
Safety-seeking behaviors prevent learning that danger is overestimated and coping abilities are underestimated.
Focus of attention: directing attention selectively towards or away from threat cues, influencing perception and emotional responses.
Spontaneous imagery: Vivid mental images enhance the sense of threat and increase anxiety levels.
Emotional reasoning: Believing that if you feel it, it must be true, without considering objective evidence.
Memory processes: Selective recall of threat and anxiety-provoking situations maintains a view of the world as personally threatening.
Interpretation of reactions to a threat event: Catastrophic conclusions exacerbate the problem and fuel further anxiety.
Prolonged worrying is unproductive and can be undermining, leading to increased distress and impaired problem-solving.
Maintaining cycles can be broken by planning interventions to interrupt these unhelpful patterns.

Treatment Approaches

Thorough assessment is essential before classifying the client's problem. Use established cognitive model and treatment protocols for specific disorders to guide intervention.
Generic anxiety cycle: trigger taps into fear, a person responds in a self-protective way, the fear is unchallenged and remains intact, ready to be triggered in the future.
Breaking the cycle involves tackling fears through cognitive restructuring, exposure, and behavior modification techniques.
Cognitive, behavioral, and physical strategies can be used to address different aspects of anxiety.
Physical strategies (e.g., relaxation techniques, breathing exercises) are useful when physical consequences impair performance or exacerbate anxiety.
Behavioral techniques tackle avoidance through systematic exposure and activity scheduling.
Cognitive approaches help clients evaluate ways of processing information and re-evaluate unhelpful perspectives through cognitive restructuring and thought challenging.
'Theory A versus Theory B' strategy tests opposing theories: 'There is danger' vs. 'I am worrying too much about danger', encouraging clients to gather evidence for and against each theory.
Anxiety disorders are an exaggerated reaction to stress, which can be addressed through techniques countering sensations, cognitions and behaviors.

Problems When Working With Anxious Clients

Mental effects of anxiety can impair clear thinking; a graded approach can help manage this by breaking down tasks into smaller, manageable steps.
Self-calming strategies (e.g., mindfulness, progressive muscle relaxation) and behavioral experiments can build confidence and reduce anxiety levels.
Avoidance is a compelling safety behavior with short-term reward; address this through self-monitoring and formulation to identify triggers and maintaining factors.
Acknowledge and address subtle forms of avoidance and safety behaviors that may not be immediately apparent.
If therapy is not working, look for subtle avoidance, superstitious behaviors, or external factors maintaining the problem.
Ensure clients are appropriately challenged without being overwhelmed by gradually increasing exposure and demands.
Therapists should also be aware of their own beliefs and potential avoidance behaviors that may impact treatment.
Address over-reliance on medication by exploring client