CBI - June 10, 2022

CBT for Anxiety Disorders:

Essential Skills

William C. Sanderson, PhD

Professor of Psychology
Director, Anxiety and Depression Clinic
Director, PhD Program in Clinical Psychology
Hofstra University
Hempstead NY
website: www.sanderson.bz
OVERVIEW

I. Introduction

II. CognitiveBT
a. cognition in development/maintenance of anxiety disorders
b. ESSENTIAL SKILL: cognitive therapy - reappraisal

III. CBehaviorT
a. behavior in development/maintenance of anxiety disorders
b. ESSENTIAL SKILL: exposure therapy

IV. Application of CBT Strategies to Address Core Psychopathological

Mechanisms for Each Anxiety Disorder (or as many as I can get to!)

→ I will take 5 minutes or so of questions after each section

→ take a quick 10 min break in the middle around
A little background…...
Standing on the shoulders of giants!
Using the understanding gained by major thinkers who have gone before in order to make
intellectual progress

David H. Barlow, PhD Aaron T. Beck, MD

Boston University University of Pennsylvania
 Lifetime Prevalence of Anxiety Disorders (U.S.): 24%

Associated with significant functional impairment

The prevalence of anxiety disorders seems to be increasing

(stress, media influences - especially social media)

Comorbidity: symptom and syndrome

Excellent resources for patients: FYI: COVID RESOURCES

sanderson.bz

Anxiety Disorders Association of America:

www.adaa.org

Anxieties.com free self-help website:

www.anxieties.com
 Pandemic Impact on Mental Health:
Anxiety Disorders

s e
increa
27%

Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic.
Open Access Published:October 08, 2021 DOI:https://doi.org/10.1016/S0140-6736(21)02143-7
Cognitive Behavioral Therapy is the most researched
psychological treatment for anxiety disorders.

Typically considered a “first-line” treatment on most existing

treatment guidelines.

In general, CBT = Meds at end of treatment

CBT > Meds at follow-up
-increased improvement
-lower relapse rate
DSM III (1980) & DSM IV (1994) Anxiety Disorders
• Panic Disorder
– with/without Agoraphobia
• Agoraphobia without panic
• Generalized Anxiety Disorder
• Specific Phobias
• Social Phobia
• Post-traumatic Stress Disorder
• Obsessive Compulsive Disorder
DSM 5 Anxiety Disorders
Trauma & Stress-Related Disorders
• Panic Disorder
• Post-traumatic Stress Disorder
• Agoraphobia • Acute Stress Disorder
• Generalized Anxiety Disorder • Adjustment Disorders (AD)
• Specific Phobias • Reactive Attachment Dis * (child)
• Social Phobia
• Selective Mutism (CD)
• Separation Anxiety Disorder (CD) Anxiety Relevant:
DSM 5 Somatic Symptom Disorders
Obsessive-Compulsive & • Illness Anxiety Disorder
related disorders (hypochondriasis)
• Obsessive Compulsive Disorder
• Body Dysmorphic Disorder (SD)
• Hoarding Disorder*
• Trichotillomania (hair-pulling) (IC)
• Excoriation (skin-picking) Disorder* IN DSM-IV:
SD = somatoform disorders
AD = adjustment disorders
IC = Impulse Control
CD= childhood disorders
* = new for DSM-5
Psychopathology of Anxiety Disorders:
An Evolutionary Model
(Evolutionary Psychopathology)

• Anxiety disorders represent features (psychological mechanisms)

that were adaptive for our ancestors.

• Anxiety is a coordinated response involving multiple systems to

facilitate dealing with threats and dangers in the environment.

• May or may not be adaptive in contemporary environment (true

alarms vs false alarms)

• What psychological mechanisms are responsible for the etiology

and maintenance of the disorder (false alarms).
 CBT (clinical psychology) should have a coherent, agreed
upon theory of human nature that is taught to all trainees.

PSYCHOPATHOLOGY
NORMAL EMOTIONS characterized by TREATMENT
HUMAN AND PSYCHOLOGICAL
PROCESSES ARE
disordered emotions
(strategies aimed at
(what are the etiological
NATURE MENTAL ADAPTATIONS and maintenance
psychopathological
mechanisms)
mechanisms)
(function)
 Empirical View of Human Nature
Fundamental Human Motives
based upon evolutionary psychology Is how well we satisfy these
motives, or perceive how we
satisfy these motives, related
The Nature of Potential Threats to Self? to our overall emotional state?

Motives = motivational.

Negative emotions compel us

to satisfy these needs.

Kendrick, 2008
Emotions → Motivational States (action tendencies)

Goal congruent or incongruent (good or bad for us)?

"Positive Emotions" – direct us towards things

that are good for our survival, mating.

"Negative Emotions"– direct us away from things

that are bad for our survival, mating.

→What’s positive or negative can be subjective and a

product of interpretation (e.g., public speaking).

There are core appraisal themes for each emotion.

 ANXIETY:
Somatic, Affective, Cognitive & Behavioral Responses to Danger

affective
Overall CBT Treatment Components
I. Therapy Relationship
a. basic skills: trust, empathy, caring, competence
b. good working alliance (collaboration, mutual goals)
c. treatment credibility (belief in the treatment)
d. motivation enhancement strategies (e.g., MI)

II. Cognitive Strategies (emotion regulation)

III. Behavioral Strategies (target avoidance behavior)

IV. Relapse Prevention (maintenance strategies)

 COGNITIVE
content: beliefs & thoughts

process: information processing style

THE COGNITIVE MODEL

Aaron T. Beck, MD
1976 1979 1985
Let’s Think About Thinking (Cognition)
In Light of Cognitive Science

System 1, System 2
Primary Appraisal?? Secondary Appraisal??
(automatic thought) (reappraisal)
 MEDIATIONAL MODEL – cognition and emotion – fear
Does this fit the two system model?

interaction of
bottom-up (low road)
and top-down (high
road) processes

(Ledoux, 2005, 2015)

Site of Emotion Regulation
Cognitive Reappraisal
 Volume Control Metaphor
Cognition as a mediator of emotion
Appraisal Theory is Central to Cognitive Therapy
Appraisal Theory of Emotion in General:
Cognitions (appraisal) mediate emotional responses, including affect and behavior

Appraisal Theory of Psychopathology:

Faulty appraisal of stimuli leads to/contributes to emotional disturbance (explains
appropriate, context specific emotions versus those that are not).

PSYCHOPATHOLOGY
NORMAL EMOTIONS characterized by TREATMENT
HUMAN AND PSYCHOLOGICAL
PROCESSES ARE
disordered emotions
(strategies aimed at
(what are the etiological
NATURE MENTAL ADAPTATIONS and maintenance
psychopathological
mechanisms)
mechanisms)
(function)
Appraisal Theory of Emotion (normal and dysfunctional emotion)

Emotion
(action tendency)
Appraisal Affect
Stimulus
Physiology
Behavior
Cognition

Specific themes of appraisals are tied to specific emotions.

 Cognitive Specificity Hypothesis
• Distorted appraisals follow themes relevant to the specific psychiatric condition.
• Disorders are characterized by different cognitive profiles.

For example:

• Depression: Negative view of self, others, and future. Core beliefs

associated with helplessness, failure, incompetence, and unlovability.

• Anxiety: Overestimation of physical and psychological threats. Core beliefs

linked with personal vulnerability, risk, dangerousness, and uncontrollability.

EVEN MORE SPECIFIC

• Social Anxiety
• Phobias
• OCD
• Panic
• Agoraphobia
• PTSD
 THE GENERIC COGNITIVE MODEL

past

present
COGNITIVE PROCESSES: 3 Levels

Automatic Thoughts
Automatic stream of thinking or images with discrete content
Typically occur out of awareness, directly accessible with training

Underlying Assumptions
Dysfunctional rules, values, expectations (if…., then…..)
Not directly accessible, determined by examining patterns of thinking

Schema
Core beliefs about oneself & others
Highly charged emotionally, extremely rigid, very low in awareness (unconscious?)
Schema:
Implicit knowledge of the “meaning” of the colors

Assumption:
If I go through a red light then it can lead to an accident or ticket

Automatic Thoughts:
Red. Red means stop. I will put my foot on the break to stop the car.
Wait for green to resume.

What goes on in cognitive reappraisal?

COGNITIVE THERAPY:
TREATMENT APPROACH
 Cognitive Treatment Strategies
Two Broad Areas: cognitive content vs cognitive process

Existential
Acceptance Cognitive
Modify
Schema Defusion
(acceptance)

Cognitive Redirect
Reappraisal Attention

Corrective ANXIETY Cognitive

Information
REDUCTION Processing
(psychoeducation)
COGNITIVE THERAPY (Reappraisal) BASIC TECHNIQUE:

→COLLABORATIVE EMPIRICISM

Goal is to elucidate and correct cognitive distortions:

→ Socratic Questioning & Guided Discovery

- Evaluate evidence for a thought or belief (trial-based CT)

- Identify cognitive distortions (next slide)
- Looking for alternative perspectives
- Hypothesis testing
Cognitive
Distortions
 Cognitive Restructuring (reappraisal):
Broad Steps Illustrate the Process

1. Identify cognitions (automatic thoughts with discrete predictions or interpretations)

e.g., I’m afraid to use the subway because if it gets stuck in between stations I’ll get so anxious I’ll have a
heart attack!!

2. Examine how these thoughts impact emotional reactions and behavior (validation)
e.g., therapist to note to pt: emotional reaction (panic) and behavior (avoidance) makes sense from the
appraisal theory we are using given the thought/belief - I’ll get so anxious I’ll have a heart attack

3. Subject each thought to logical analysis and identify cognitive distortions -- facilitate
cognitive flexibility instead of certainty
1) What evidence is there that this is possible? What do I know about anxiety? What are the facts?

2) Identify distortions: Jumping to conclusions, emotional reasoning, mental filter, catastrophizing

4. Generate a “rational response” → logical analysis facilitates a reappraisal

e.g., I’ve read about anxiety and other people’s experience and know it can not kill me. While anxiety is very
very uncomfortable, it is not dangerous. And while I would be fearful if the train stopped, I will be able to
tolerate it until it resumes -- that’s what has happened in the past when I had anxiety provoking
situations come up that I could not escape from. In fact, the only way to get over this phobia is to be
willing to experience the anxiety and see nothing happens - so this can be an opportunity to test that.
 Appraisal Model of Emotion with REAPPRAISAL

↓
intervention

Emotion
(action tendencies) REAPPRAISAL
Affect (conscious appraisal)

STIMULUS APPRAISAL up- or down-regulation

Physiology content related to appraisal
← Behavior modification

←
← Cognition

↵
←
←
← ←
← ←
← ←
← ←
←← ←
Thought record guides this process
Beware of Faulty Information Processing which may interfere with reappraisal:

Mood-congruent bias: mood influences processing

Confirmatory bias: expectations influence processing (implicit process)

Self-fulfilling prophecy: expected behavior can confirm previous expectations

-distinguish between self-fulfilling outcomes vs actual outcomes
Cognitive Restructuring Aids (priming):

index cards
smartphone notes
smartphone recorder

Notebook – log in order to collect ongoing data in a systematic fashion -

Keep a record of what is actually happening?
 PSYCHOPATHOLOGY
characterized by
NORMAL EMOTIONS disordered emotions TREATMENT
AND PSYCHOLOGICAL
HUMAN PROCESSES ARE case conceptualization
disorder specific
modification
MENTAL ADAPTATIONS focus on etiological and of strategies aimed at
NATURE (function)
maintenance psychopathological
mechanisms
mechanisms:
DISORDER SPECIFIC
 PSYCHO- TREATMENT
NORMAL
HUMAN PATHOLOGY (strategies aimed at
EMOTIONS (etiological and psychopathological
NATURE maintenance mechanisms
(function)
mechanisms)

Cognitive mechanisms in anxiety disorders:

1. Overestimation of danger (cognitive bias)

2. Focus of attention on danger related cues (hypervigilance)
3. Lack of acceptance/tolerance of anxiety (anxiety sensitivity)
4. Unwillingness to accept existential realities (tolerance of
uncertainty, risk)
5. Avoidance of anxiety provoking thoughts/affect
(cognitive avoidance, thought suppression)
Worry vs Anticipatory Anxiety vs Fear

WORRY
focus on potential future threat

ANTICIPATORY ANXIETY
focus on future threat

FEAR (Panic)
imminent threat
When dealing with anxiety it is likely you will have to work
on existential acceptance
“Existential” Part of Treatment
Is Anxiety the Shadow of Intelligence?
The Specter of Death?
(Liddell, 1949)

Central to human behavior is the

motivation to stay alive - evolution
would have it no other way.

Anxiety is the primary “system” for

keeping us alive.

Humans appear to unique compared

to all species in that they are aware of
their ultimate demise!
EXISTENTIAL ACCEPTANCE

-Need to develop tolerance/acceptance of

Risk/Uncertainty - keep in proportion

-Manage risks rather than eliminate

Some individuals want 100% certainty that nothing bad will happen which may be a
factor in the development of anxiety disorders in general (I want a guarantee that my
flight won’t crash!)

The following three points are important as we try to help individuals works towards
accepting the existential reality of our existence and consequently decrease fear
driven by the attempt of obtaining certainty:

(1) One can never be 100% certain that nothing will happen at any point in the future
starting now,

(2) We take risks every day living our lives, and there is no alternative; very few
of us would want to live in a bubble to maximize safety and give up our lifestyle,

(3) The best one can do is manage risks, not eliminate them fully.
BEHAVIORAL
 PSYCHO- TREATMENT
NORMAL
HUMAN PATHOLOGY (strategies aimed at
EMOTIONS (etiological and psychopathological
NATURE maintenance mechanisms
(function)
mechanisms)

Behavioral mechanisms involved in the etiology and maintenance of

anxiety disorders:

ESCAPE AND AVOIDANCE BEHAVIOR →

Reward Based Learning and Negative Reinforcement
NEGATIVE REINFORCEMENT:
crucial in development and maintenance of anxiety disorders
EXPOSURE THERAPY: Undoing the process of negative reinforcement.

GOALS:
→ Toleration and acceptance of anxiety and panic while exposed to fear producing stimuli
→ Removing avoidance, escape, and the use of safety signals as a way to cope with anxiety
→ Ultimately break association between stimulus and maladaptive fear response (extinction)
→ Increase confidence and sense of mastery of anxiety and fear provoking stimuli

Exposure to Phobic Stimuli

a. Rationale for situational exposure for the patient
- Explain process of negative reinforcement (avoidance, escape) ultimately increasing the fear-response.
- Explain extinction (or learning a new response -- inhibitory learning)
- Discuss imaginal versus in vivo exposure

b. Preparing for exposure

- Develop a fear hierarchy of phobic situations
***Must be VERY SPECIFIC (attention to fear gradient, variations for the same stimulus, safety signals)
What to do with cognition during exposure → thought content and thought process
→ Reappraisal -- change the content
→Acceptance/cognitive defusion -- accept thoughts/feelings as they are
→Attention modification (mindfulness?) -- refocus attention away from anxiogenic thoughts

Imaginal Exposure (in and out of session)

- Processing the stimulus (focus on all aspects of the emotional response)
- Inoculation
- Priming corrective response
- Cognitive coping: reappraisal, acceptance, attention modification

In Vivo Exposure
- systematic exposure based upon hierarchy of items
- gradual (systematic) versus flooding
- no relaxation attempts (reciprocal inhibition)
- Cognitive coping: reappraisal, acceptance, attention modification

In-vivo
a. Systematic (gradual) vs flooding
b. self-directed, other-assisted, therapist-assisted
Imaginal Exposure (in and out of session)
- Processing the stimulus (focus on all aspects of the emotional response: cog, phys, affect, behav)
- Priming corrective response (rehearsal)
- Inoculation (used prior to in vivo exposure)
- Cognitive coping: reappraisal, acceptance, attention modification

HOW TO CONDUCT? -> Use my “stage play” metaphor

Two principles to guide you:
- Set the stage: detail increases immersion & anxiety
- Provide movement (e.g., a series of scenes)

Therapist recommendation→ close your eyes while you ask questions so you can be guided by creating a
vivid scene for yourself.
In Vivo Exposure
- systematic exposure to feared stimuli based upon hierarchy of items
- gradual (systematic) versus flooding
- no relaxation attempts! (reciprocal inhibition)
- Cognitive coping: reappraisal, acceptance, attention modification

In vivo exposure can be self-directed, other-assisted, therapist-assisted

→ Strategies to increase patient compliance:

gentle pressure + motivational enhancement (e.g. MI)
increase accountability to therapist/treatment (e.g., email compliance)
self-monitoring
problem-solving approach when difficulty complying
EXPOSURE as BEHAVIORAL EXPERIMENTS FOR COGNITIVE CHANGE:
set up “experiments” to evaluate validity of anxious predictions
(focus on facilitating disconfirmation of negative expectations)

→ Facilitate inhibitory learning (see next slide)

POINT OF ESCAPE expectation of what would

happen if no escape
Inhibitory learning: learning which inhibits previous learning.
Strategies to maximize inhibitory learning during exposure
cognitive enhancements?

From Craske 2012

To facilitate
inhibitory
learning during
exposure
exercises conduct
it as an
experiment to
test the validity of
thoughts:
CRASH COURSE IN APPLICATION OF CBT TO
ADDRESS THE PSYCHOPATHOLOGY OF EACH
ANXIETY DISORDER.
Understanding the Psychopathological Mechanisms (Maintaining
Factors) Is Essential to Deliver the Most Effective Intervention

For each disorder:

1. Cognitive Psychopathology
2. Behavioral Psychopathology
3. Treatment strategies to address 1 & 2
e.g., snakes, spiders, bugs, rodents, dogs, vomiting, enclosed places (e.g., trains, planes),
heights, separation anxiety

“special cases” where exposure must be modified → needles, choking (globus hystericus)
 Psychopathology: Specific Phobias
COGNITIVE:
→ overestimation of the danger of the stimulus
→ catastrophizing scenarios (e.g., dog will bite and you will get rabies, plane will crash,
trapped in an elevator and never get rescued)

→ misinterpretation of inherent fear response (prepared phobias) to various stimuli

- discuss prepared versus conditioned phobias
- believe the feeling is accurate

BEHAVIORAL:
→ Lack of contact with stimulus (e.g., snakes, public speaking)
→ Avoidance of stimulus that one anticipates with fear
→ Escape from the stimulus when experiences fear
Cognitive Therapy: Modify
Fearful Interpretations and Belief
Related to the Stimulus

→ Specific Stimulus Risk-Perception Modification

- Provide accurate information about the threat of the stimulus.
- Use appropriate websites such as CDC when relevant
- How Risky Is It, Really? is an excellent guide for info.

→ Don’t believe what you feel

- Discuss evolutionary model of phobias
- True-alarms vs false-alarms:
Discrimination of dangerous stimuli and nondangerous stimuli
(e.g., spider in AZ desert versus one in NYC, or standing on a roof versus looking out a window).

→ Explain process of exposure to maximize compliance

 Systematic Exposure

Fear hierarchy
COVID
RELEVANT

Blood/Injury/Needle Phobia
America Undercover Panic
video - patient descriptions, illustrations
of cbt
 Psychopathology
Panic Disorder and Agoraphobia

COGNITIVE:
Catastrophic misinterpretation of symptoms of anxiety/fear
(physical, cognitive, behavioral, affective): fear of fear

→ fear of dying
→ losing control or doing something uncontrolled
→ fear of going crazy

BEHAVIORAL:
a. Avoidance and escape from agoraphobic situations (situational exposure = treatment) -- see MI -
next slide
→ situations where one may be trapped or escape would be difficult during a panic attack
→ situations where one may not be able to get help if needed during a panic attack

b. Avoidance of symptoms that resemble anxiety/panic (interoceptive exposure = treatment)

→ general avoidance of physical symptoms of anxiety/fear (e.g., cardiac, respiratory, temperature)
→ can include physical stimuli such as caffeine, humid hot places, exercise
Cognitive Model of Panic

catastrophic misinterpretation = panic

Focus of Cognitive Reappraisal
Consider ANXIETY SENSITIVITY as predisposing factor to panic

Fear is a normal, necessary, and adaptive response.

affect: fear
physiological: increased autonomic arousal
cognitive: focus on the danger
behavioral: urgent desire to flee

Fear is NOT dangerous. One will not die, lose control, or go crazy. See experiment below as illustration

Fear is very uncomfortable and compelling. It evolved to grab your attention.

Distinguish between Adaptive vs Maladaptive Fear -- true alarms versus false alarms
consider -- if one was held up with a gun they would not question or fear their fear response.

Experiment:
Flight 1549
155 on board
What happened to
them?
Example of Panic Disorder Thought Record from Sanderson & Wetzler (1992) ..
Situational Exposure for Panic
sample hierarchy:
1. ride elevator in building x one floor with spouse 30
2. take bus from home into city with friend 45
3. walk 1 mile from home - alone 35
4. take train from home into city with friend 45
5. attend a play 75
6. ride elevator one floor in building x - alone 85
7. take train from home into city - alone 95
8. drive 10 miles on the highway away from home - alone 95
Interoceptive Exposure for Panic
Examples of items for Interoceptive Exposure:
Respiratory symptoms → suffocation (e.g., holding breath, voluntary hyperventilation, breathing through snorkel)
Cardiac symptoms → heart attack (e.g., exercises such as use of treadmill, walking up stairs, caffeine)
Dizziness/Unsteadiness → fainting (e.g., spinning in a chair, shaking head back and forth)
Sedative stimuli → loss of control (e.g., a cold remedy, alcohol, tranquilizers)
Depersonalization/Derealization → mental catastrophe (e.g., bright lights, blinking lights, repeated blinking,
staring at complex patterns such as spirals, stripes)

sample hierarchy (heart rate, breathing, arousal):

1. run on treadmill for 5 min - HR = 90 (someone home) 30
2. breathe through a snorkel of 1 min 35
3. drink 4 ounces of coffee 35
4. breathe through a snorkel for 2 min 45
5. run on treadmill for 5 min - HR = 110 (someone home) 50
6. drink 8 ounces of coffee 65
7. breathe through a snorkel for 5 min 75
8. run on treadmill for 5 min - HR= 110 (no one home) 100
 Psychopathology
Social Anxiety Disorder
COGNITIVE:
→ negative cognitions about self (low self-esteem, self-critical)

→ unrealistic standards of social performance (expectation of failure)

→ view of others as extremely evaluative and critical (anticipate rejection)

→ post-event rumination (negative memories reinforce above)

BEHAVIORAL: → a broad range of social avoidance
Exposure for Social Anxiety Disorder
sample hierarchy

1. make a comment about the weather to a cashier at Starbucks 30

2. arrange to go out for lunch with a friend 40
3. ask 1 question in a meeting at work 45
4. use a credit card at the grocery store where you must sign 50
5. invite someone you don’t know well for coffee 75
6. use a public restroom when someone else is using it as well 85
7. invite a small group of acquaintances for a party 95
8. offer to give a presentation to your work group 95
→ Insight Specifier:
→ good or fair
→ poor
→ absent insight/delusional beliefs
 OCD: Definition of terms
• Obsessions
Intrusive and nonsensical thoughts, images, or urges that one tries to
resist or eliminate
• Compulsions
Thoughts or actions to relieve anxiety triggered by the obsession

The existence of compulsions warrants a modification of exposure:

ERP (exposure and response prevention)
 Psychopathology
Obsessive Compulsive Disorder
OCD contamination subtype (anxiety and disgust):

Cognitive: overestimation of danger (contamination of various stimuli)

Behavioral: avoidance of stimuli

If contact → COMPULSIVE BEHAVIOR TO NEUTRALIZE THE DANGER
Cognitive Reappraisal to address specific unrealistic
beliefs and appraisals related to contamination (cognitive
distortions)

see the following as an irony of handwashing too much:

https://www.huffpost.com/entry/washing-hands-too-much_n_5b7b0141e4b0a5b1febdce5f
Systematic Exposure:

I. Imaginal (inoculation) and In-vivo

1. use doorknob entering office (delay hw 30min) 30

2. read the magazine in the dentist’s waiting room 40
3. sit on seat on subway - no changing clothes 55
4. use office restroom doorknob (delay hw 30min) 70
5. use doorknob entering office - no washing 75
6. place groceries in home cabinet without cleaning 80
7. read magazine in GP office - no hw 95
8. office restroom doorknob - no hw 100

II. Imaginal exposure to disastrous consequences (flooding)

Imaginal focus on the concern actually happening in increasing detail, guide
pt to take it to its most extreme form to maximize anxiety.
OCD harming/aggressive subtype (anxiety, shame, guilt)

Cognitive:
-Experience of unwanted intrusive thoughts related to aggression.
-Fear might harm others “deliberately” (push someone into traffic)
-Violent images come to mind (e.g., picking up a knife and stabbing someone)
-Fear of blurting out obscenities or insults
-Fear will harm others because not careful enough (e.g., motor vehicle accident)

TWO PROCESSES TO CONSIDER FOR TREATMENT

- misinterpretation of the personal meaning of thoughts (thought-action fusion =
thinking about an action is equivalent to actually carrying out that action)

- unacceptability of thoughts leads to attempts at thought suppression

Behavioral:
avoidance of external cues that trigger thoughts (e.g., knives, driving, train platforms)

VIDEO: Unwanted Thoughts: The Dangers Of 'Pure O'

OCD harming/aggressive subtype (anxiety, shame, guilt)

Cognitive:
-Experience of unwanted intrusive thoughts related to aggression.
-Fear might harm others “deliberately” (push someone into traffic)
-Violent images come to mind (e.g., picking up a knife and stabbing someone)
-Fear of blurting out obscenities or insults
-Fear will harm others because not careful enough (e.g., motor vehicle accident)

TWO PROCESSES TO CONSIDER FOR TREATMENT

- misinterpretation of the personal meaning of thoughts (thought-action fusion =
thinking about an action is equivalent to actually carrying out that action)

- unacceptability of thoughts leads to attempts at thought suppression

Behavioral:
avoidance of external cues that trigger thoughts (e.g., knives, driving, train platforms)

VIDEO: Unwanted Thoughts: The Dangers Of 'Pure O'

Cognitive:

Normalize aggressive/sexual thoughts as part of human

experience

Focus on CBT model - thoughts are normal, appraisal of

them as “bad” is not.

Distinguish between thoughts and actions for holding self

“accountable”
Systematic Exposure:

Imaginal Exposure: to the content of the obsessions

sample hierarchy

1. 1 min IE intentionally hitting someone with car 50

2. 1 min IE stabbing dog 60
3. 5 min IE intentionally hitting someone with car 75
4. 5 min IE stabbing dog 85
5. 15 min IE intentionally hitting someone with car 90
6. 15 min IE stabbing dog 100
Systematic Exposure:

In-vivo Exposure: external cues that trigger obsessions

sample hierarchy

1. leaving knife on table with dog in room 30

2. driving car in parking lot at x store 40
3. holding knife in hand with dog in room 1 min 60
4. taking subway when platform is crowded 65
5. driving car in parking lot at y crowded store 75
6. petting dog with knife in other hand 1 min 90
7. driving car in y parking lot at night 100
8. standing close behind person on train platform 100
Example of OCD Thought Record - from McGinn & Sanderson (1999)
 Psychopathology
Post-Traumatic Stress Disorder (PTSD)

COGNITIVE:

Process: Failure to process (avoidance of) traumatic memory as a result of

cognitive avoidance (reasons to be discussed below which must be dealt
with during therapy)

Content:
– Impact of the trauma alters the individual’s belief system
– How does the trauma redefine the individuals sense of self?

BEHAVIORAL:
Avoidance of external cues associated with trauma.
 Imaginal Exposure To Traumatic Event

Goal:
– Extinguish the associations between the
thoughts/images and anxiety/fear thereby
decreasing the need to use avoidance strategies.

prolonged exposure → anxiety reduction secondary to habituation

FOA VIDEO “The Cruelest Cure”

Treatment: Prolonged Exposure Therapy for Post-Traumatic Stress Disorder
Guidelines for Conducting Imaginal Exposure

Trauma scene re-lived in imagination, patient asked

to describe it aloud (present tense).

Therapist should guide this by “setting the scene”

- What did you see?
- How did you behave? Others?
- What were you thinking?
- How were you feeling?
- What did you fear would happen?
- Additional: smells, sounds, etc.

Then move to next scene. And so on.

Guidelines continued

Systematic Exposure:
to increase the intensity of the image, gradually
increase the duration and intensity (details) of the trauma.

• Anxiety levels are monitored every 5 minutes throughout the exposure period to know
when to stop increasing intensity.

• Imaginal exposure periods should eventually be approximately 30 minutes in length.

Descriptions are repeated several times each session and audio recorded.

• Homework: Patients are instructed to listen to the recording at home once a day.

SAMPLE HIERARCHY:

1. One minute IE 30
2. Two minutes IE 40
3. Five minutes IE 50
4. 10 minutes IE 75
5. 30 minutes IE 100
Cognitive Reappraisal & Cognitive Processing Therapy
Cognitive restructuring involves an extended, systematic effort to:

-Educate about role of thoughts and beliefs in causing or maintaining

emotional distress following trauma

-Identify distressing thoughts and beliefs (stuck points - e.g., beliefs that get
in the say of processing the memory)
moral injury (survivors guilt):
-Perceived responsibility
-Perceived insufficient justification for actions taken
-Perceived violation of values
-Perceived preventability/foreseeability of negative outcomes

-Discuss, review evidence, and generate alternative cognitions to:

(1) correct distortions (eg, over-responsibility, unrealistic expectations)
(2) facilitate acceptance when appropriate (“war is hell”).
 Cognitive Restructuring:
common emotions, themes, and cognitions
Guilt: response to the perception of doing something wrong.
“I was a coward, that’s why I survived that battle”
“I shot that innocent person by mistake”

Shame: response to feeling humiliated about one’s behavior/action.

“My first reaction was to hide” “I panicked in the situation”

Anger: directed at self for not behaving as expected or desired

“If I would have shot that person the others would have survived.
It’s my fault.”

Sadness: response to loss (includes bereavement, loss of ideals, loss of previous sense of self)
“How can I live with myself after what I’ve done”
“How can I go on after losing so many friends”
 SYSTEMATIC EXPOSURE
general guidelines

• Systematic exposure to specific situations that cue fear or reminders of the

traumatic event.

• Construct a list of situations from less anxiety provoking to extremely anxiety

provoking.

Sample hierarchy from Foa video on sexual assault PTSD.

1. Go into church and do not sit in last row (have people sit behind you) 50
2. Walk on a busy city street having people walk behind you 60
3. Stay at home alone at night 70
4. Agree to a dinner date 80
 Psychopathology
Generalized Anxiety Disorder (GAD)
COGNITIVE:
Chronic worry - future oriented negative expectation (what if…..!?)

Leads to general state of anxiety (mood congruent processing)

Negative expectation across a variety of life areas

the world is a dangerous place!! = core sense of vulnerability

BEHAVIORAL:
Avoidance and reassurance seeking serve to maintain the chronic state of worry.

Avoidance = failure to full process concerns (escape from worry leads to negative
reinforcement - relief).

Reassurance seeking (similar to a compulsion)does not facilitate tolerating

reasonable amounts of uncertainty.
 IMAGINAL EXPOSURE:
Stimulus Control & Worry Exposure
Goals:
• a. decrease cues that initiate worry
• b. desensitize anxiety response to specific worries
• c. facilitate processing of worries: distancing, problem solving

Procedure:
• 1. Set a time and place to worry each day (30min)
• 2. Each time pt has a worry, write it down and postpone worry until later.
• 3. Teach pt to focus attention on immediate environment as a way of
distracting from the immediate worry (mindfulness training).
• 4. Pt uses worry time to focus on the worries in detail
encourage pt to take it to its most extreme form to
maximize anxiety
 Behavioral Component of GAD:
Exposure & Response Prevention
Focus on behaviors that ultimately maintain worry process (negative
reinforcement)
Avoidance (Ex) Reassurance Seeking (RP)
Over-preparation (RP) Excessive Checking (RP)
Procrastination (Ex)

Identify specific behaviors and implement change.

FOR EXAMPLE:

RP: eliminate calling their college age child who goes out for the evening to be sure he/she “got
there.”

EX: have patient go for check of blood pressure to be sure it is not elevated.
Thank you for your attention!

THE END
Questions?
EXTRA SLIDES
BELOW
- not included in the talk above
 References:

Abramowitz et al. (2011). Exposure Therapy for Anxiety. Guilford Press.

Adriaens & De Block (2011). Maladapting Minds: Philosophy, Psychiatry, and Evolutionary
Theory. Oxford Press.

Barlow et al. (2011). Unified Protocol for Transdiagnostic Treatment of Emotional Disorders.
Oxford Press.

Clark & Beck (2010). Cognitive Therapy of Anxiety Disorders. Guilford Press.

Roemer & Orsillo (2009) Mindfulness-& Acceptance-Based Behavioral Therapies in Practice.

Guilford Press.

Wells (2009). Metacognitive Therapy for Anxiety and Depression. Guilford Press

Yalom (1980) Existential Psychotherapy. Basic Books.

Young & Klosko. (2003). Schema Therapy: A Practitioners Guide. Guilford Press.
 COGNITIVE INTERVENTIONS FOR ANXIETY (continued)

COGNITIVE INTERVENTIONS: Meta-Cognitive Strategies

Focus on the Cognitive Processing of Information

(rather than modifying content)

3. Cognitive Processing
Focus on decreasing cognitive avoidance and facilitating processing/integration
-Exposure to anxiety provoking thoughts
(e.g., exposure to worry, post-trauma reactions, catastrophic thoughts,
social rejection, etc.)
. Attention Refocus/Modification (Cognitive Bias Modification)
Focus attention away from threat cues to disrupt biased information
processing
-Increase presence in situation – focus on external details (awareness)
-Focused on non-threatening stimuli in situation (e.g., friendly face)
-Focus on neutral stimulus (e.g., breathing)
6. Modification of Core Beliefs/Schema
Existential Aspect: Anxiety and the Human Condition (e.g., Yalom, May)

Is Anxiety the Shadow of Intelligence?

The Specter of Death?
(Liddell, 1949)

Pathological anxiety may result from the inability to confront and accept the givens
of existence – e.g., the inevitability of death, physical dangers, social rejection,
failure.

Goal: Acceptance of some anxiety as part of life.

-Need to develop tolerance/acceptance of risk/uncertainty
-Goal of life: Manage risks rather than eliminate
 Modification of Core Beliefs/Schema
Existential Aspect: Anxiety and the Human Condition (e.g., Yalom, May)

Existential Therapy: pathological anxiety may result from the inability to confront
and accept the givens of existence – e.g., the inevitability of death, physical
dangers, social rejection, failure.

Goal: Acceptance of “anxiety” - risk, uncertainty, danger – as necessary part of

living.
 Modification of Core Beliefs

Schema-Focused Therapy (Young)

Focus is on identifying and modifying deeply entrenched beliefs that tend to be

central to one’s sense of self or view of the world.

Goal: Insight into, and awareness of, “biased” information processing will
allow for correction
 Cognitive Process: Focus of Intervention

Emotion
CORE
(action
BELIEFS Appraisal tendencies)
Stimulus
Affect
(schema)
Physiology
Behavior
COGNITION

↓
Focus on emotion driven cognition: avoidance, escape (suppression), attention (hypervigilance)
Cognitive: Modification of the thought process
Meta-Cognitive Strategies:
Cognitive Defusion (acceptance vs lack of acceptance of thought)

Cognitive Processing (avoidance/suppression vs exposure)

Attention Refocusing/Modification (threat cues vs alternative cues)

 Meta-Cognitive Strategies

Mindfulness & Cognitive Defusion

focus is on description/awareness (mindfulness)and acceptance
(defusion) of thoughts/emotions rather than changing them

Roemer & Orsillo, 2011

META –COGNITIVE: ACCEPTANCE BASED STRATEGIES

Mindful Breathing (15min practice - training mind to focus)

Mindful Awareness – general training to attend to details of objects, activities, situations
(describe the pen, eating a food, instruments in a song, objects in a room)

Cognitive Defusion (decentering, distancing)

Mindful awareness of thoughts and emotions
Shift from the contents of awareness to the awareness itself
Stepping outside of oneself to become a “detached observer” and witness of their internal state
- use skills developed from mindfulness training
- intensive focus is on awareness, description, and ultimately acceptance
rather than changing or suppressing)

Recognition that thoughts are just thoughts - not necessarily reality

Shift in perspective from thoughts represent reality to thoughts are only an internal event
e.g., I am never going to be ready for this presentation becomes I am having the thought that I will never be ready for
this presentation.

Recognition that thoughts are transient.

Thoughts/emotions are transient rather than a stable entity
e.g., I am a depressed person becomes Right now I feel depressed but depression is not me and will change
 Meta-Cognitive Strategies
Cognitive Processing
Focus on decreasing cognitive avoidance and facilitating
processing/integration

Exposure to anxiety provoking thoughts

(e.g., exposure to worry, post-trauma reactions, catastrophic thoughts,
social rejection, etc.)
 Meta-Cognitive Strategies

Attention Refocus/Modification
Focus attention away from threat cues to disrupt biased information
processing

Increase presence in situation – focus on external details

(awareness)
Focused on nonthreatening stimuli in situation (e.g., friendly face)
Focus on neutral stimulus (breathing)
 Proposed Sequence of Cognitive Interventions

PSYCHOEDUCATION
(Corrective Information)

COGNITIVE REAPPRAISAL

CORE BELIEFS (Insight)

Schema Modification
Existential Acceptance

META-COGNITIVE - ACCEPTANCE BASED

Cognitive Defusion
Cognitive Processing
Attention Refocus
Additional behavioral strategies
1. Behavioral Activation (depression)
2. Skills building when indicated:
assertiveness training
social skills enhancement
sleep hygiene
relaxation strategies
organizational skills and goal setting
stress management
problem-solving