Anxiety Disorders

Master in Psychology
General Sanitary
OBSESSIVE COMPULSIVE DISORDER,
DISORDERS RELATED TO
STRESSORS AND EVENTS
TRAUMATICS AND DISORDERS OF
ANXIETY:
Phobias, Panic Disorder,
Agoraphobia, Social Phobia, Anxiety
separation and selective mutism.
Anxiety Disorders are the most common mental disorders that occur most
frequently. It includes a group of conditions that share extreme or
pathological anxiety as their main alteration.
tdd anim tnminl L nidd dr ntndid
INDEX
1. Justification……………………………………………………………………………………….……….. P. 3
2. Introduction……………………………………………………………………………………………….. P. 4
3. Description of Anxiety Disorders…………………………………………………. P. 12
Master in Psychology General Sanitary 1
INDEX 2
JUSTIFICATION 9
INTRODUCTION 10
DESCRIPTION OF ANXIETY DISORDERS 23
DESCRIPTION OF DISORDERS RELATED TO STRESSORS AND 37
TRAUMATIC EVENTS 37
DESCRIPTION OF OBSESSIVE-COMPULSIVE DISORDERS 44
Types of OCD 47
TREATMENT OF ANXIETY DISORDERS 53
Thought Affect/Physiological Activation Conduct. 60
1) Personal identification data: 69
2) Reason for consultation: 69
3) Symptoms: 69
4) History of the problem and previous treatments: 70
5) Personal and family history: 71
^ Evolution data-results: 72
3) Cognitive Behavioral Alternatives to Vicious Circles, Distortions and
Personal Assumptions. Practice through homework assignments. 79
5) Cognitive-Behavioral Alternatives to Unspoken Rules. 79
A) BEHAVIORAL TECHNIQUES: 79
B) COGNITIVE TECHNIQUES: 80
3) Symptoms: 81
^ Session 1: 100
= Session 2: 101
^ Session 3: 102
> Session 4: 102
^ Session 5: 102
^ Session 6: 102
= Session 7: 102
CAMPUS
UNIVERSITY
^ Session 8: 103
= Session 9: 104
^ Session 14: 104
= Session 15: 104
3) Symptoms: 122
^ Session #1: 123
^ Session #2: 126
^ Session #3: 126
^ Post-Treatment: 126
4) Modification of the Assumptions Personals who do vulnerable to the 138
> Session #1: 147
> Session No. 2: 147
• Situation. In literature class talking about astrology with some classmates. 147
■ . Situation: At the pub, a girl asked me to sit with her. 148
^ Results: 151
4) Identification of Personal Assumptions and Examination of their Validity
(idem to previous section). 160
3) Symptoms: 162
^ Session #1 to #8: 165
> Session #12 to #30: 165
> Session #30 to #45: 165
Semee'ad ) 167
EMER- -a 167
1) Evaluation and conceptualization of problems : 193
2) Therapeutic socialization: 194
1. Same as above with obsessions and... 196
4. Typical rules for response prevention: 196
4. Treatment of associated Anxiety-Depression problems . 198
Obsessive Fears (Downward Arrow) Alternatives 199
1) Identification data : 199
3) Symptoms: 201
Anxiety disorders [4]

CAMPUS
UNIVERSITY
> Session #1 and #2: 205
= Session No. 8: 206
F Session No. 10: 206
^ Session #11: 206
^ Session nº13: 206
^ Session #14: 208
^ Session #16: 208
^ Session #17: 208
1) Functional-Cognitive or Psychological Exploration: 221
2) Information Techniques (Cognitive Reconceptualization): 221
5) Treatment of Anxiety and/or Associated Depression 15 . 222
7) Exposure to phobic fears of death and/or illness : 222
DIFFICULTIES IN EVALUATION 223
PHARMACOLOGICAL TREATMENTS 226
BASIC RULES FOR THE PREVENTION OF ANXIETY AND STRESS
PROBLEMS 18 229
1. The diet: 229
2. Rest: 229
4. Organization: 230
5. Problem Solving and Decision Making: 230
6. Interpretation of situations and problems: 231
Attributions and Self-esteem: 231
8. Relationships with others (partner, friends, colleagues, family, etc.): 232
9. Specific Training in Anxiety and Stress Control Techniques: 232
DSM-5. MODIFICATIONS REGARDING THE DSM-IV-TR 233
BIBLIOGRAPHY 234
^ Generalized Anxiety Disorder…………………………………………………………. P. 19

^ Separation Anxiety Disorder and Selective Mutism……………………. P. 20
4. Description of Disorders related to stressors and a. traumatic P. 21

CAMPUS
5. UNIVERSITY
Description of Obsessive-Compulsive disorders ……………………………………………… P. 25
Related Disorders………………………………………………………………………….. P. 28
Master in Psychology General Sanitary 1
INDEX 2
JUSTIFICATION 9
INTRODUCTION 10
DESCRIPTION OF ANXIETY DISORDERS 23
DESCRIPTION OF DISORDERS RELATED TO STRESSORS AND 37
TRAUMATIC EVENTS 37
DESCRIPTION OF OBSESSIVE-COMPULSIVE DISORDERS 44
Types of OCD 47
TREATMENT OF ANXIETY DISORDERS 53
Thought Affect/Physiological Activation Conduct. 60
3) Symptoms: 69
^ Evolution data-results: 72
Personal Assumptions. Practice through homework assignments. 79
5) Cognitive-Behavioral Alternatives to Unspoken Rules. 79
A) BEHAVIORAL TECHNIQUES: 79
B) COGNITIVE TECHNIQUES: 80
3) Symptoms: 81
^ Session 1: 100
= Session 2: 101
^ Session 3: 102
> Session 4: 102
^ Session 5: 102
^ Session 6: 102
= Session 7: 102
^ Session 8: 103
= Session 9: 104
^ Session 14: 104

CAMPUS
UNIVERSITY
= Session 15: 104
3) Symptoms: 122
^ Session #1: 123
^ Session #2: 126
^ Session #3: 126
^ Post-Treatment: 126
4) Modification of the Assumptions Personals who do vulnerable to the 138
> Session #1: 147
• Situation. In literature class talking about astrology with some classmates. 147
■ . Situation: At the pub, a girl asked me to sit with her. 148
^ Results: 151
(idem to previous section). 160
3) Symptoms: 162
^ Session #1 to #8: 165
> Session #12 to #30: 165
> Session #30 to #45: 165
Semee'ad ) 167
EMER- -a 167
1) Evaluation and conceptualization of problems : 193
2) Therapeutic socialization: 194
1. Same as above with obsessions and... 196
4. Typical rules for response prevention: 196
4. Treatment of associated Anxiety-Depression problems . 198
Obsessive Fears (Downward Arrow) Alternatives 199
1) Identification data : 199
3) Symptoms: 201
> Session #1 and #2: 205

CAMPUS
UNIVERSITY
= Session No. 8: 206
^ Session #11: 206
^ Session nº13: 206
^ Session #14: 208
^ Session #16: 208
^ Session #17: 208
1) Functional-Cognitive or Psychological Exploration: 221
2) Information Techniques (Cognitive Reconceptualization): 221
5) Treatment of Anxiety and/or Associated Depression 15 . 222
7) Exposure to phobic fears of death and/or illness : 222
DIFFICULTIES IN EVALUATION 223
PHARMACOLOGICAL TREATMENTS 226
BASIC RULES FOR THE PREVENTION OF ANXIETY AND STRESS
PROBLEMS 18 229
1. The diet: 229
2. Rest: 229
4. Organization: 230
5. Problem Solving and Decision Making: 230
6. Interpretation of situations and problems: 231
Attributions and Self-esteem: 231
8. Relationships with others (partner, friends, colleagues, family, etc.): 232
9. Specific Training in Anxiety and Stress Control Techniques: 232
DSM-5. MODIFICATIONS REGARDING THE DSM-IV-TR 233
BIBLIOGRAPHY 234
a.
6. Treatments for Anxiety Disorders………………………………………………. P. 31
Panic Disorder………………………………………………………………………………. P. 34
Agoraphobia………………………………………..……………………………………………………… P. 42
Specific Phobias………………………………………………………………………………..… P. 70
Social anxiety disorder……………………………………………………………………………… P. 80
Generalized anxiety disorder………………………………………………………. P. 94

CAMPUS
7. UNIVERSITY
Treatment of disorders related to stressors and a. traumatic. … P. 114
8. Obsessive Compulsive Disorder and related …………………………………………. P. 118
Hypochondria………………………………………..……………………………………………………. P. 136
9. Difficulties in Evaluation………………………………………………………………………. P. 141
10. Pharmacological Treatments…………………………………………………………..……………. P. 144
11. Basic Rules for the Prevention of Anxiety and Stress Problems……… P. 147
12. DSM-5. Modifications with respect to the DSM-IV-TR P. 151
13. Bibliography…………………………………………………………………………………………………. P. 152

CAMPUS
UNIVERSITY
JUSTIFICATION
Anxiety is at the root of many, if not all, of our

psychological disorders. It is, physically, a type of fear
response, which involves the activation of the sympathetic
nervous system, in response to a dangerous situation.
More specifically, anxiety is the anticipation of danger,
learned through repeated stressful situations or trauma.
Some people are naturally more sensitive to stress, and
are therefore more likely to experience anxiety and develop Anxiety Disorders. But everyone
becomes sensitive to stress and trauma with repeated experiences: Each experience "tunes up"
the nervous system to respond more quickly and deeply to perceived danger.
We often talk about anxiety as some kind of genetic problem, and also as something
based on childhood trauma. But long-term stress is probably most often the root of Anxiety
Disorders. The constant demands of living in poverty, discrimination, war and abuse are part of
everyday life for millions of people around the world.
There are basically five ways that people respond to the relentless stress and trauma
and anxiety that comes with it:
1. Anxiety Disorders - the topic of this section.
2. Self-medication , leading to alcoholism and other drug addictions.
3. Depression – lock yourself away (the common Western response).
4. Somatization – body aches and pains (a common non-Western response).
5. Dissociation - various "trance" states and, ultimately, psychosis.
In this way a person depends on many things, such as his personality, his culture, his
specific circumstances and so on.
Anxiety disorders
CAMPUS
UNIVERSITY
INTRODUCTION
To understand what Anxiety Disorders are, you must first think

about normality. We must remember that all people have the
capacity to react with anxiety, because it is an emotional response.
Afterwards we will be able to better understand Anxiety Disorder as
a pathology, as an excess in frequency, intensity, duration, etc. of
the anxiety response, or simply as an inadequate response to the
demands of the situation.
Emotions are reactions that are experienced as a strong shock to the mood or affective
state. This reaction usually has a marked pleasant or unpleasant accent and is accompanied by
the perception of organic or bodily changes, sometimes very intense (emotional experience).
The bodily changes are characterized by a high physiological activation, especially of the
Autonomous Nervous System (excessive sweating, increased heart rate, etc.) and the somatic
nervous system (muscle tension), although other systems (hormonal, immune, etc.) are also
activated. etc.) This reaction can also be reflected in typical facial expressions, easily identifiable
by any external observer (expressions of joy, sadness, fear, anger, etc.), as well as in other
motor behaviors that are also observable, such as some movements, postures, changes. voice,
etc.
Generally, emotions arise as a reaction to a specific
stimulating situation, however, they can also be caused by some
type of internal information from the individual himself, such as:
memories, proprioceptive information (sensations), etc. The
interpretation of a given situation is not the same for all
individuals, sometimes not even for the same individual at
different times. Whether or not an emotion arises will depend on how this situation is
interpreted, as well as whether the emotion will be positive (pleasant) or negative
Anxiety disorders
CAMPUS
UNIVERSITY
(unpleasant).
Anxiety disorders
CAMPUS
UNIVERSITY
Anxiety is a natural emotion, present in all humans, which is very adaptive because it
puts us on alert for a possible threat; However, sometimes it is experienced as an unpleasant
experience (negative emotion), especially when it reaches a high intensity, which is reflected in
strong somatic changes, some of which are perceived by the individual; Furthermore, this
reaction, when it is very intense, can cause a loss of control over our normal behavior.
What is anxiety? It is a natural emotion. Therefore, anxiety has some similarities with other
emotional reactions, such as happiness, anger, sadness, fear, etc. Anxiety is experienced as an
unpleasant, negative emotion that arises in a situation in which the individual perceives a
threat (possible negative consequences). To face this situation and try to reduce the negative
consequences, the individual must become alert. The emotional reaction can be observed at a
triple level: cognitive-subjective (experience), physiological (bodily changes) and motor
(behavioral-observable).
^ At a cognitive-subjective level , anxiety is characterized by feelings of: discomfort, worry,
hypervigilance, tension, fear, insecurity, feeling of loss of control, perception of strong
physiological changes (cardiac, respiratory, etc.) .
^ At a physiological level , anxiety is characterized by the activation of different systems,
mainly the Autonomous Nervous System and the Motor Nervous System, although others
are also activated, such as the Central Nervous System, or the Endocrine System, or the
Immune System. Of all the changes that occur, the individual only perceives some changes
in responses such as: heart rate, respiratory rate, sweating, peripheral temperature, muscle
tension, gastric sensations, etc. The persistence of these physiological changes can lead to a
series of transitory psychophysiological disorders, such as headaches, insomnia, erectile
dysfunction, muscle contractures, gastric dysfunctions, etc.
^ At a motor or observable level , anxiety manifests itself as: motor restlessness,
hyperactivity, repetitive movements, communication difficulties (stuttering), avoidance of
feared situations, substance use (food, drink, tobacco, etc.), crying, tension in facial
expression, etc.
Anxiety disorders
CAMPUS
UNIVERSITY
Cognitive activity is related to physiological activation. When cognitively evaluating the

consequences of a situation, an increase in physiological activation occurs. There are many
situations that generate anxiety. For example, watching a thriller movie puts us on alert and
activates us. In everyday life, ambiguous situations, without a certain outcome, also activate us
and put us on alert . These changes are normal in all individuals, although there are individual
differences in the intensity of the physiological responses caused by the same stimulus.
Intense Physiological Changes do not have to be pathological, but are generally
considered adaptive responses of the individual to the demands of the situation. A person who
is very activated in an exam or when speaking in public should not be surprised in principle,
since they need more energy resources, more attention, in short more coping resources than if
they were calmly resting. This increased physiological activity to a certain extent is normal,
although it may be interpreted as a danger by some people. Now, in some individuals, very
intense physiological responses become chronic, that is, they can last for an excessive period of
time. To understand what happens with a metaphor we could say that such individuals go very
fast all the time, which implies more energy expenditure, difficulties resting, discomfort, and
even the possibility of something failing. We could say that high physiological activation,
produced by situations that generate anxiety, is not pathological in principle, but if its intensity
is excessive and chronic it can affect health.
For example : Muscle tension is generally higher in situations in which we need to be
active and give a quick or forceful response to the demands of the situation. But a person who
studies an opposition exam every day for eight hours to get a job (an exam in which a lot is at
stake), can accumulate day after day too much tension in the neck, shoulders, back, frontal
muscles, etc., which can cause, firstly, pain, and secondly, muscle contracture.
Another example : A person who argues a lot with his partner, or with his boss, who
remains angry for a long time afterwards, thinking about the argument, what he said, what he
should have said, what he should do, etc., Stays under tension for a long time, but if you do not
resolve this tension by talking, you can reach high levels of blood pressure. The patients
Anxiety disorders
CAMPUS
UNIVERSITY
Hypertensive people have higher scores on tests that evaluate internal anger (anger directed
inward, unexpressed, rumination, etc.).
The study of the pathology of the physiological systems that are activated in emotion
began in the 1950s. It is assumed that psychosomatic or psychophysiological disorders (such as
some headaches, back pain, some arrhythmias, the most common types of arterial
hypertension - essential hypertension -, some gastric discomfort, etc.) could be produced by an
excess of intensity. and frequency of activation of the physiological responses of the system
that suffers the injury or dysfunction (cardiovascular, respiratory, etc.).
To explain these organic dysfunctions that occur with high levels of anxiety, we could
say that it is a dysfunction of an organic system (gastric, respiratory, cardiovascular, motor,
etc.) that is working excessively and maintains this activity for too long. In turn, the organic
disorder produces psychological discomfort, produces more anxiety and, therefore, an increase
in the activity of that system, thus increasing the probability of developing and maintaining this
organic dysfunction to a greater degree. In the psychological clinic we can find people who
suffer from arrhythmias, chronic pain, muscle contractures, asthma, gastric disorders,
dermatological disorders, etc. Why, if they are physical disorders, are they in the psychological
consultation? Because they have very high levels of anxiety that must also be treated.
What are the disorders associated with high levels of anxiety? Anxiety is present in many
disorders, both mental and physical:
1. MENTAL DISORDERS.
^ The highest levels of anxiety are usually found in individuals who suffer from so-called
Anxiety Disorders , which include:
• Panic Attacks or Anxiety Crisis.

• Agoraphobia.
• Social phobia.
• Specific Phobia.
• Generalized anxiety.
Anxiety disorders
CAMPUS
UNIVERSITY
• Obsessive Compulsive Disorder.
Anxiety disorders
CAMPUS
UNIVERSITY
• Posttraumatic Stress Disorder.

• Separation disorder
• Selective mutism
• Substance Abuse Disorder, etc.
^ But anxiety, in addition to being the main symptom in this type of psychopathological
disorders or mental disorders, is a predominant symptom in many other
Psychological Disorders , such as :
• Mood Disorders (Major Depression, Dysthymia, etc.).
• Addictions (Tobacco, Alcohol, Caffeine, Cannabis Derivatives, Cocaine, Heroin,

etc.).
• Eating Disorders (Anorexia, Bulimia).

• Sleep disorders.
• Sexual Disorders.
• Impulse Control Disorders (Pathological Gambling, Trichotillomania, etc.).
• Somatoform Disorders (Hypochondria, Somatization, Conversion, etc.).
2. On the other hand, anxiety is also present in a series of PHYSICAL DISORDERS , such as :
^ Psychophysiological disorders, among which the following should be mentioned:
• Cardiovascular Disorders (Coronary Heart Disease, Hypertension, Arrhythmias,

etc.).
• Disorders Digestive (Irritable Colon, Sore).

• Disorders Respiratory (Asthma).
• Disorders Dermatological (Psoriasis, Acne, Eczema).
• And other Psychophysiological Disorders (Tension Headaches, Chronic Pain,

Sexual Dysfunctions, Infertility, etc.).
^ In turn, anxiety is present in Other Physical Disorders , such as:
• Disorders related to the immune system : Cancer, Rheumatoid Arthritis, etc.
Anxiety disorders
CAMPUS
UNIVERSITY
• And in general in any chronic disorder that involves a significant loss of quality of
life or a threat to survival, such as:
Anxiety disorders
CAMPUS
UNIVERSITY
Chronic Pain, Terminal Illness, etc.
Positive emotional expressions facilitate communication, while negative emotional

expressions cause distance and serve to announce discomfort and even a possible attack. The
main forms of emotional expression (smiling, crying, facial expressions of joy, sadness, fear,
etc.) are universal in different cultures. Any healthy individual can perceive if another individual
in his or her group, and even from another culture, is happy, angry, sad, or afraid.
All individuals are nervous (anxious) on multiple occasions, however, generally, we try
to hide it. Let's say that it is not well seen to show anger, sadness, fear, tension, loss of
emotional control, etc. Some people are very afraid of the possibility that others will notice
their manifestations of anxiety. These people usually present high scores on inventories that
evaluate evaluation anxiety and some even develop a true Social Phobia, avoiding social
situations due to the anxiety they cause, by constantly thinking (when they find themselves in
these types of situations). ) that their behavior is not appropriate, they make a fool of
themselves, etc. The expression of emotions is also related to health: it has sometimes been
found that more expressive individuals enjoy better health, while individuals who express their
emotions less become ill more frequently.
The intense (acute) anxiety reaction is not always pathological, but in most cases it can
be very adaptive. For example: if the situation that provokes it requires a strong alarm reaction
that prepares us for action (if it requires great concentration on a task that requires many
attention resources), or if it requires great activation physiological (because we need to tense
our muscles more, pump more blood, more oxygen, etc.), this anxiety reaction will help us
respond better to the demands of this situation.
More than 15% of the general population suffers from an Anxiety Disorder at some
point in their lives, which consists of a series of reactions (at a cognitive, physiological and
motor level) that are too intense, or too frequent, or simply little adjusted to the situation in
which the individual finds himself. These manifestations become
Anxiety disorders
CAMPUS
UNIVERSITY
pathological in many cases, making the normal life of these people difficult, or making them
feel very unpleasant experiences in some situations.
Anxiety symptoms reach very high levels in people who suffer from one or more
Anxiety Disorders. Most patients suffer from two or more of these disorders at the same time.
Only one third of patients with Anxiety Disorders are diagnosed with a single anxiety disorder.
People without an Anxiety Disorder may experience similar symptoms to people who
suffer from an Anxiety Disorder. The most frequent manifestations of anxiety or symptoms are:
1. At the Cognitive-Subjective Level:
• Worry.
• Fear.
• Unsafety.
• Difficulty deciding.
• Fear.
• Negative thoughts about oneself.
• Negative thoughts about our actions towards others.
• Fear that they will realize our difficulties.
• Fear of loss of control.
• Difficulties thinking, studying, or concentrating, etc.
2. At the Physiological Level:
• Sweating.
• Muscle tension.
• Palpitations.
• Tachycardia.
• Shaking.
• Stomach discomfort.
• Other gastric discomfort.
• Respiratory difficulties.
• Dry mouth.
Anxiety disorders
CAMPUS
UNIVERSITY
• Difficulties swallowing.
• Headaches.
• Dizziness.
• Nausea.
• Stomach discomfort.
• Shiver, etc.
3. At the Motor or Observable Level:
• Avoidance of feared situations.

• Smoking, eating or drinking excessively.
• Motor restlessness (repetitive movements, scratching, touching, etc.).
• Going from one place to another without a specific purpose.
• Stutter.
• Cry.
• Being paralyzed, etc.
In many cases, a person's anxiety is caused by their own manifestations of anxiety: they
are very afraid of the unpleasant experience of anxiety, but this fear produces the anxiety (so it
is a vicious circle).
There are practically universal criteria to determine if a person's behavior can be
diagnosed as an Anxiety Disorder. These criteria are included in the two most important
classifications of Mental (or Psychopathological) Disorders:
• DSM-V (American Psychiatric Association, APA)4 .

4breathe. I thought it would go away but it got worse. I couldn't get up because I was falling, I
couldn't breathe, I thought I was going to die, that I wasn't going to get to the doctor, I was
shaking all over. I went through a terrible fear. The doctor has ruled out any physical illness and
has prescribed me T. I refused to take it, but now I need it to sleep and to be able to get up from
bed.
A Panic Attack is a distinct period of intense fear or discomfort
that is associated with numerous somatic and cognitive
symptoms. These symptoms include: palpitations, sweating,
Anxiety disorders
CAMPUS
•
UNIVERSITY
ICD-10 (World Health Organization, WHO).
If we take a look at both classifications we find that the criteria for diagnosing an
Anxiety Disorder are similar.
Anxiety Disorders do not differ much from each other due to the manifestations or
responses of anxiety, but rather there are differences between these disorders.
shaking, difficulty breathing, feeling of choking or suffocation,

chest pain, nausea or gastrointestinal upset, dizziness, tingling
sensation, chills or
flushing and "hot flashes." The attack typically has an abrupt onset, increasing to maximum
intensity within 10 to 15 minutes. Most people mention the fear of dying, of cervical cancer, and
the result was negative. My blood tests are normal (cholesterol a little high, 240). They
recommended muscle relaxants to me, M., but the problem has continued, although more
attenuated, it is true. Dizziness always occurs with movement, never lying down and at rest, in
such a way that I have come to fear going outside, due to the discomfort that this caused me. I
always run everywhere, I can't help it, like an hour or more, on one occasion it was longer, the
next day I'm nervous, very uneasy. The fact is that everyone I consulted told me it was anxiety, I
put myself in the hands of a psychologist (a month ago) to help me determine the cause of this
situation, we are working on it but, in the meantime, I am becoming afraid of it Anyway, I am
very afraid of the attacks recurring and that is why I no longer lead a normal life, I have stopped
going out with friends to overwhelming places, or with loud music, etc. I even stopped working
this week because I'm afraid of public transport and I can't drive to work. More and more I think
that my life is crap because I can't do what I want, I'm not the same as before, I have a lot of
fears and when a situation arises that worries me and the attack starts, I'm unable to control it
and stop it. I know it's all in my mind but I can't control myself and in the meantime... I'm
getting desperate. I think that this psychologist is not working for me, I am very impatient now
and I want this to be resolved so that I can go back to being the same as before. I am going to
consult with a psychiatrist this week but I am also distressed by the fact that these professionals
are very expensive, very expensive, and honestly my financial resources are rather scarce. I need
help to get out of this because I have the feeling that I am getting deeper and deeper, even
more afraid of leaving the house.
These common conditions are characterized by marked fear of specific objects or
Anxiety disorders
CAMPUS
UNIVERSITY
linked to the situational areas in which patients with different Anxiety Disorders present
difficulties or high levels of anxiety.
Thus, for example, individuals with Social Phobia present differences with patients who
suffer from Generalized Anxiety in social situations, rather than in the overall intensity of their
anxiety symptoms.
DESCRIPTION OF ANXIETY DISORDERS
Panic Attacks and Panic Disorder
situations . Exposure to the object of the Phobia, whether in real life or through imagination or
video, always causes intense anxiety, which may include a panic attack (linked to a situation).
Adults generally recognize that this intense fear is irrational. However, for
Anxiety disorders
CAMPUS
UNIVERSITY
Example 1: Hello, my name is Silvia, I am 28 years old, and I live in Palma de

Mallorca. Last Sunday, I suffered a serious anxiety attack. I had been feeling
bad for a while, I couldn't breathe, I had stomach problems, I couldn't
concentrate,............. Until Sunday I had been able to control it but, suddenly,
and without any direct cause, I began to not be able to
Anxiety disorders
CAMPUS
UNIVERSITY
bed. I still feel short of breath and I'm terrified that what happened on Sunday will happen
again. People try to help me but I know the whole theory perfectly, although I can't apply it. I
don't know who I can turn to, I don't know how I can help myself and, ultimately, I don't know if
I can get out of this on my own. I'm scared to death. I would like, if possible, to guide me in some
type of strategies that improve even a little my quality of life.
Example 2: Hello, good afternoon. I am a 26-year-old boy whose life has

changed for the worse in the last year and a half with this terrible problem,
anxiety. It all started in the most terrible way, driving. Imagine at 130 km/hour
coming from Madrid (I live in Zaragoza), at night, and suddenly, I start to get
dizzy, to feel muscle spasms all over my body.
body, and a suffocating feeling of loss of control that almost made me crash. They were the
most distressing two hours of my life, since I was 150 km from my house, and although I
stopped at a service area to rest from what I thought was dizziness, I decided to continue, with
the terrible consequences of driving with a acute anxiety attack for more than two hours, at a
maximum of 80 km/hour. Well, from then on my life changed, the symptoms of anxiety began:
dizziness, fear of going anywhere, and the worst thing, it seriously affected my work. I was
under treatment, based on P. and T. for almost six months, and although I never felt completely
well, the symptoms seemed to be subsiding. Six months after stopping treatment, those
symptoms have returned, and I don't think a general practitioner can help me, and I wouldn't
want to gorge myself on medications like before.
Anxiety disorders
CAMPUS
UNIVERSITY
"go crazy" or lose control of emotions or behavior. The experiences generally cause a strong
desire to escape or flee from the place where the attack begins and, when associated with chest
pain or difficulty breathing, often the result is seeking help from an emergency room. a hospital
or other type of urgent assistance. However, an attack rarely lasts more than 30 minutes.
Panic Disorder is twice as common among women as men. The age of onset is most
common between late adolescence and adulthood, an onset after age 50 is relatively
uncommon.
Panic Attacks are in themselves traumatic, and thus lead to increased anxiety, which
makes the person more alert and more likely to misinterpret situations, as well as bodily
symptoms, and thus have more panic attacks. panic. They are the classic example of
anticipatory anxiety: Being afraid of having a panic attack is precisely what causes a panic
attack!
Agoraphobia
Example 1: Approximately 4 months ago I started with general malaise,

dizziness (things don't move, it's as if I were moving), nervousness, like an
internal tremor, dry mouth, poor quality of sleep, muscle tension, etc. I have
been to several Social Security doctors because the diagnosis was: cervical
problem. I had x-rays
Anxiety disorders
CAMPUS
UNIVERSITY
anxiety a fear of not being able to do everything I have to do. On one occasion I went to the
emergency room because I felt terrible, they did an electrocardiogram and neurological tests,
and the result was negative. I was prescribed more muscle relaxants. The fact is that the
problem is not solved and I am tired of no one giving me a solution. My question is this: Could it
be due to a stress or anxiety problem? Can these symptoms described coincide with anxiety? I
am 46 years old.
Example 2: Hello. My name is Puri and I am 25 years old. For about 3 months I
have been suffering from anxiety attacks or crises according to what I have
been diagnosed with. Specifically, the attack has hit me about 4 times and I
have felt horrible: it starts with a feeling of overwhelm, pressure in the head,
my heart races incredibly fast, and I start to get very nervous, like that for a
while.
Anxiety disorders
CAMPUS
UNIVERSITY
The ancient term Agoraphobia translates from Greek as the fear of

an open market. Agoraphobia today describes the severe and
generalized anxiety of being in situations where escape may be
difficult or the avoidance of situations such as being alone outside
the home, traveling in a car, bus or plane, or being in a crowded
area.
Most people who present at [are seen by] health specialists
Mental develop Agoraphobia after the onset of Panic Disorder. Agoraphobia is best understood
as a negative behavioral result of repeated Panic Attacks and subsequent restlessness, worry
and avoidance .
Agoraphobia is approximately twice as common among women as men. Since 95% of
agoraphobics also have Panic Disorder, perhaps the two categories are actually one.
Specific Phobias
Example: My name is Lola. I am 40 years old. I work as a technician in a

multinational. I am married and have two children, ages 4 and 7. I would like
you to help me solve some problems that I am unable to solve on my own: Fear
of flying. For work reasons I am forced to take planes quite frequently, but for
some years now this means of
Transportation makes me very insecure, which has considerably reduced my quality of life. Is
there any effective method to eliminate this problem?
Anxiety disorders
CAMPUS
UNIVERSITY
They generally avoid the phobic stimulus or endure the exposure with great difficulty. The most
common Specific Phobias include the following feared stimuli or situations: animals (especially
snakes, rodents, birds and dogs), insects (especially spiders and bees or wasps), heights,
elevators, flying, driving cars, water , storms, and blood or injections.
Approximately 8% of the adult population suffers from one or more Specific Phobias in
a year........... Typically, Specific Phobias begin in childhood, although there is a second "peak"
of onset in the mid-20s of adulthood. Most Phobias persist for years or even decades, and
relatively few remit [improve] spontaneously or without treatment.
Specific Phobias generally do not result from exposure to a single traumatic event (i.e.,
being bitten by a dog or nearly drowning). Instead, there is evidence of Phobia in other family
members and social or vicarious learning of Phobias. Unexpected spontaneous panic attacks
also appear to play a role in the development of Specific Phobia, although the particular pattern
of avoidance is much more focal and circumscribed.
Phobias can be understood in part as a matter of conditioned fear: a strong anxiety or
panic attack that is experienced at the same time as the phobic object, so it is associated with
that object. Most of the time, panic is not a response to the phobic object (a snake, mouse, or
spider), but to the loss of safety experienced when someone (like your mom or dad) responds
dramatically to that object. . If mom or dad is scared, I should be very scared! It also seems that
many Phobias have a strong integrated component. Many people are at least uncomfortable, if
not phobic, around snakes, mice, spiders, reptiles, heights, confined spaces, barking dogs, and
birds of prey. These things make us fearful before we even know their potential danger. These
fears make some sense, considering the dangers they could have posed to our ancestors. Of
course, it is not the figure of a bird, a snake, a spider, or a dog that leads directly to the fear
response. It is rather a bird's swooping motion, gliding, unpredictable presence, growling, and
so on.
Anxiety disorders
CAMPUS
UNIVERSITY
SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)
Example 1: Hello. My name is María, I am 34 years old and I am from

Barcelona, for almost 20 years I have suffered from depression, stress,
anxiety... but when I got to high school I had a terrible time, that was when I
entered my first depression, it was a pilgrimage to psychiatrists and
psychologists and now I have been diagnosed with Social Phobia. I am
extroverted, but crowds scare me, as well as work, it is impossible for me to work without
taking a tranquilizer pill, now I am studying my second degree, but remotely, I started another
degree but the first one came to class to choose a good place where they wouldn't see me, and I
was a good student... I couldn't stand it, I quit after two months and didn't go to class, they left
me the notes. In my first career it was different, I had a terrible time but that's where I started
taking psychotropic drugs, just like when I started working so I wouldn't have an anxiety attack.
I suffer from anxiety attacks often, my social environment is not the most ideal for overcoming
problems, but I am aware that everything lies in me. Right now I am taking two drugs: P. and
V.; the S. I feel terrible and they tell me there is nothing else. Furthermore, they have never
made me do psychotherapy.
Example 2: I am a very shy person, I am 31 years old and I have a degree in

Computer Science, and I don't know how to relate socially, which makes me
anxious because I don't receive affection from anyone, and since I don't go out
much, I stay at home and that makes that I give more thought to everything,
when in reality I would like to go out. A few months ago I met a man that I
really liked, however, approaching him made me so anxious that I couldn't. Now I try to just be
friends with him, although I would like to be something more. My biggest problem is what has
Anxiety disorders
CAMPUS
UNIVERSITY
happened to me twice now. They have offered me two good, well-paid jobs in cities close to
where I live and I have gone to work in those cities, but the problem arose as soon as I arrived
and found myself locked in a house that is not mine and far from my mother. I became so
anxious that I was unable to live alone, so I had to return home and now everything is worse
because I want to overcome my fear of being outside and become a sociable woman who
knows how to defend herself; However, it scares me very much and I think I will not be
Anxiety disorders
CAMPUS
UNIVERSITY
capable, although I will not stop fighting. I feel like my life is empty if I can't do what I want.
Now I wanted to work again in another city, I was very excited and I also wanted to have a
romantic relationship with that person that I like so much; However, I find myself incapable, no
matter how much I want to. I have very good will and I struggle with shyness and anxiety but I
see that I need help from a psychologist.
Social Phobia, also known as Social Anxiety Disorder, describes people

with marked and persistent anxiety in social situations, including
presentations and public speaking. The critical element of fear is the
possibility of embarrassment or ridicule. Like Specific Phobias, the fear
is recognized by adults as excessive or irrational, but the feared social
situation is avoided or tolerated with great discomfort. Many people with Social Phobia worry
about whether others will see their anxiety symptoms (for example, shaking, sweating, or
blushing), or hesitating or speaking quickly; or being judged for being weak, stupid, or "crazy."
Fears of fainting, loss of bowel or bladder control, or having a blank mind are also common.
Social Phobias in general are associated with significant anticipatory anxiety which in turn can
impair performance and increase embarrassment.
Social Phobia is more common in women. Social Phobia typically begins in childhood or
adolescence and, for many, is associated with traits of shyness and social inhibition. Public
humiliation, terrible embarrassment, or other stressful experiences can cause intensified
difficulties. Once the disorder has established itself, complete remissions without treatment are
rare. More frequently, the severity of symptoms and impairments tend to fluctuate in relation
to the demands of vocational training and the stability of social relationships.
Social Phobia is another example of anticipatory anxiety: The expectation of social
shame causes anxiety that leads to social shame... In the US, Social Phobia often begins in early
Anxiety disorders
CAMPUS
UNIVERSITY
adolescence, when shy children are often humiliated by peers. This is common in a highly
competitive society like ours. Furthermore, people in lower social positions in a very
Anxiety disorders
CAMPUS
UNIVERSITY
hierarchical (and yes, ours is one) are often victims of this way, and develop Social Phobia.
In Japan, there is an interesting variation of Social Phobia called Taijin kyofusho
(Interpersonal Phobia). This implies great anxiety that other people find your appearance, your
face, and even your smell unpleasant.
Generalized anxiety disorder
Example: I have always thought that being so nervous was an intrinsic part of
my personality, but the truth is that the more time passes, that state of nerves
or anxiety becomes more and more unbearable. So I have always told myself
or thought that being like this had no remedy. However, it is reaching a point
where it does not allow me to live normally, I am always tense, on alert, I
cannot relax, it is difficult for me to fall asleep at night, my hands sweat almost constantly and
almost any situation makes me react. with nerves and tension. I know that this type of behavior,
of general concern, is not normal and it can (and I can't with it) me. I have come to despair. To
the point that sometimes I feel great frustration. Sometimes, I can't help but think why am I like
this? At those times, these thoughts depress me and make me want to disappear. They make
me feel unbearably depressed (which I hate and reject). The thing is that I want with all my
might to end this horrible feeling. I have many things to fight for and to live for, but I am aware
that I have to find a solution to this damn problem that limits me. Of course, I am not a
specialist, but if I know myself, and after having read about the subject, I think that perhaps I
suffer from GENERALIZED ANXIETY.
Generalized Anxiety Disorder is defined by a prolonged (duration > 6

months) period of anxiety and worry (duration > 6 months), accompanied
Anxiety disorders
CAMPUS
UNIVERSITY
by several associated symptoms. These symptoms include: muscle tension, easy fatigue,
difficulty
Anxiety disorders
CAMPUS
UNIVERSITY
concentrate, insomnia and irritability..... Excessive worries often concern many areas, including
work, relationships, finances, family well-being, potential, and looming deadlines. Somatic
symptoms of anxiety are common, as are sporadic panic attacks.
Generalized Anxiety Disorder is more common in women, with a sex ratio of around 2
women to 1 man. The prevalence in 1-year-old children is approximately 3 percent. About 50
percent of cases begin in childhood or adolescence.
In Latin America, some people suffer from something called nerves. They feel great
anxiety, insomnia, headaches, dizziness, even palpitations. It usually begins with a loss of
someone close, or with family conflicts. Since family is everything in many cultures, family
problems are often the root of psychological problems.
Separation anxiety disorder and selective mutism
Both disorders, despite being considered anxiety disorders in the DSM-V, will be
explained in detail in the Childhood and Adolescence Disorders module.
DESCRIPTION OF DISORDERS RELATED TO STRESSORS AND

TRAUMATIC EVENTS
Anxiety disorders
CAMPUS
UNIVERSITY
Example: My name is Carlos, I belong to a Police Corps and I was the target of
a terrorist attack in 1985, consisting of the placement of a device (sticky
bomb) placed in the underbody of my private vehicle. After the event my chest
hurts almost continuously and my stomach swells, I also have dizziness,
sometimes with loss of consciousness for a few seconds, but I have to hold
on!; I am losing weight and with each passing day I am getting worse, the symptoms appear
more often, but I do not know how to identify them, later in time I will come to understand that
they are the symptoms of “POST-TRAUMATIC STRESS” (an illness that I currently suffer from) . I
am totally disoriented, lost, alone, I feel like dying. I sleep badly, I dream of attacks, of bombs,
of terrorists chasing me, of armed confrontations; Even the explosion of a firecracker or a loud
bang, startles and scares me, it seems that my heart is going to burst out of my mouth and my
pulse accelerates, as if I were going to have a heart attack. And I'm still alone! This loneliness is
killing me, I repeatedly think that ETA It did not kill me, but the State is little by little killing me,
with a prolonged and painful agony (on occasions I have thought about taking my own life, if I
have not done so, it has been for my family, my wife and my son). My loneliness is tremendous,
I search and I can't find anyone to talk to, with whom to share my feelings, my problems. My
colleagues avoid me, the Commandos avoid me, some civilian friends avoid me, everyone
avoids me. I'm a stinker! The difficulties over the years have been numerous, to be able to
collect them all. It was and still is very difficult for me to stand anywhere talking to people, I
have to sit down, or else my legs start to shake and I fall to the ground. I have a feeling of
tachycardia, chest pain, almost continuous (I have had electrocardiograms and they are all
negative, I have nothing). Almost permanent dry mouth. Tremors in the hands; Lately, I can't
master them. I have a hard time concentrating, I have to leave most things undone and come
back the next day or the next. I, who have always expressed myself correctly, both in writing
and orally, for a while now (between 6 or 7 years), find it increasingly difficult to come up with
that word or that phrase. It's hard for me to express myself. I think I stutter sometimes. I don't
Anxiety disorders
CAMPUS
UNIVERSITY
feel like doing any activities. It's hard for me to go for a walk alone. Or go nowhere
Anxiety disorders
CAMPUS
UNIVERSITY
only. I can't take a city bus, I feel like I'm going to pass out, the same thing happens to me with
the train. I only feel safe if I travel by car, but on short journeys. I cannot leave my place of
residence, if I go out a few kilometers, I feel that I do not control the vehicle and that I lose
consciousness. I have a headache. I cannot go far from my home or from the vehicle, if I have
used it. Most of the time, if I do a somewhat longer route, I have to sit anywhere, since the
feeling of dizziness, of not being able to focus my eyes anywhere, is absolute. My sexual activity
is zero, I have no erection or desire, I have been this way for 7 years. I am permanently tense.
My back and legs, especially, hurt at the end of the day. Sometimes I have attacks of anger,
although I try to overcome it (I have always been calm). I usually have stomach pain, sometimes
followed by diarrhea, as well as heartburn in the stomach. Feeling like vomiting, sometimes,
without being able to do so. I go through periods when I can't sleep, or I sleep little, with
constant nightmares (normally 90% related to the attack); I'm disabling artifacts, or stopping
"commands", but always on the same topic; alternating with other seasons, that I am
practically asleep all day and all night. I have suffered two serious episodes of eczema.
Sometimes they occur again, but more attenuated. Already in the provincial capital, and before
that in the town of the attack, I went through all these types of experiences, but I took
Tranxiliun 5 or 10, and waited for new episodes. Some of these symptoms began to develop two
or four months after the attack. Over time they have been increasing and, one could say that
since 1988 or 1989, they have been taking over me, to the current point, where I am an
"invalid." Since I can't lead a normal work, social or family life. Which leads me to despair,
having to depend in some way on my wife or child. And, all this, despite my constant fight, but
always or on most occasions I am defeated. Both the GP, the occupational doctor, the
psychologist or psychiatrist encourage me and teach me Relaxation techniques, but on the
street they are of no use to me, I can't do well. In this sense I have to add that when I leave the
house to walk, I pace myself well, but as I get further away from home, I open my legs, this way
I feel like I have greater balance. Sick days are becoming more frequent, long in duration and
painful, since colleagues do not understand them. Specifically, I spent the entire year 2000 on
sick leave, prior to sick leave of two to three months, during the years 1986 onwards. I always
Anxiety disorders
CAMPUS
find UNIVERSITY
myself
Anxiety disorders
CAMPUS
UNIVERSITY
tired. I have cried a lot, only I know that! And, on many occasions I have wished that I had died
in the attack, at least this way I would not be suffering what I have been suffering for years and
at the same time I would not make my family suffer. My family, social and work life has never
been the same as it was before. Now, I am nervous almost every day, but not for fear of having
an attack, it is because of the disease that over time and without help of any kind has become
chronic, making you almost an invalid. Currently and after passing the Medical Court, I have
been diagnosed with “CHRONIC POST-TRAUMATIC STRESS OF UNCERTAIN REVERSIBILITY” and
“ABSOLUTE INCAPACITY FOR ANY TYPE OF PROFESSION OR TRADE, AS A CONSEQUENCE OF A
TERRORIST ATTACK”. As well as a 50% disability. Waiting for the Resolution that the Ministry of
Defense may take regarding my future, which could be anything. I continue with periodic visits
to the Psychiatrist and Psychologist, but the progress is not as I would like. It seems that I have
been “anchored” in time.
Acute Stress Disorder refers to anxiety and behavioral disorders that

develop during the first month after exposure to extreme trauma . In
general, symptoms of Acute Stress Disorder may begin during or
shortly after the trauma. Such extreme traumatic events include rape
or other severe physical assaults, near-death experiences in accidents,
witnessing a murder, and combat (war). The symptom of dissociation, reflecting a perceptual
detachment of the mind from the emotional state or even the body, is a critical characteristic.
Dissociation is also characterized by a sense of the world as a dreamlike or unreal place and
may be accompanied by poor memory of concrete events, which in severe form is known as
dissociative amnesia [memory loss, not based on of physical causes]. Other characteristics of an
Acute Stress Disorder are symptoms of Generalized Anxiety and hyperarousal, avoidance of
situations or stimuli that trigger memories of the trauma, and persistent, intrusive memories of
the event through flashbacks, dreams, or recurring thoughts or images. visuals.
Due to the more prolonged nature of Post-Traumatic Stress Disorder (relative to Acute
Stress Disorder) , a series of changes are generally observed,
Anxiety disorders
CAMPUS
UNIVERSITY
including decreased self-esteem, loss of beliefs held by people or society, hopelessness, a sense
of permanent damage, and difficulties in previously established relationships. Substance abuse
often develops, especially related to alcohol, marijuana, and sedative and hypnotic drugs.
Around 50% of Post-Traumatic Stress cases remit within 6 months. For the rest, the
disorder usually persists for years and can dominate the sufferer's life. A longitudinal [long-
term] study of Vietnam veterans, for example, found that 15% of veterans suffered from Post-
Traumatic Stress Disorder 19 years after combat exposure. In the general population, the one-
year prevalence is approximately 3.6 percent, with women having almost twice the prevalence
as men. The highest rates of Post-Traumatic Stress Disorder are found among women who are
victims of crime, rape in particular, as well as among torture and concentration camp survivors.
PTSD seems to involve a series of problems with the hippocampus, which, if you
remember, is dedicated to moving short-term memory into long-term storage. First,
emotionally intense events lead to intense memories called flash memory. It appears that these
flashes may actually be partially stored in the amygdala, which represents the fears involved.
Additionally, prolonged stress from experiences like war or childhood abuse actually begins to
destroy tissue in the hippocampus, making it more difficult to create new long-term memories.
Studies show that people who have suffered long-term trauma have 8 to 12% less
hippocampus. The net result could be that they are, in some sense, trapped in their traumatic
past.
PTSD is an example of an Anxiety Disorder that also involves some of the other trauma
responses we mentioned above. Many self-medicate with alcohol and drugs, making the
problem worse. Many are seriously depressed. There is also a degree of dissociation involved,
meaning that victims become numb, distant, showing little emotion. They no longer feel real.
Perhaps this is actually an adaptive response to traumatic stress. We encounter this type of
dissociation commonly in refugee populations, which
Anxiety disorders
CAMPUS
UNIVERSITY
Sometimes it can seem like zombies. They may simply be protecting themselves from additional
psychological pain.
DESCRIPTION OF OBSESSIVE-COMPULSIVE DISORDERS
Example: Hello, my name is Santiago and I am 25 years old. I suffer from

Obsessive Compulsive Disorder. It all started when I left school almost 8 years
ago, since then I have started to feel very strange sensations: first it started
with a very acute stomach pain, then I started to feel a lot of sexual
excitement. To claim that excitement I opted for masturbation, but the pain in
my stomach persisted; Then I began to feel more sensations, such as a lot of body heat...,
sensations of being contaminated, of feeling disgusted by certain kinds of foods such as beans,
sardines, etc.; I also feel that my whole body is contaminated with beans or sardines or certain
kinds of foods. In those moments is when my body heat rises, I feel very hot and very
disgusting. I also feel that where I walk is contaminated with this type of food and I feel a lot of
despair... I have taken medications such as: ciblex, fluoxetine, sertraline, ansietil, paroxetine,
clonazepam, valproic acid, goval; But I have only felt relief for a maximum of 3 days and from
then on I feel the same symptoms again. This illness has limited my life, sometimes I feel like
committing suicide because I think there is no solution to this anymore. The side effects of those
medications are horrible and apart from the disgust at things, the disgust at people touching
me, the disgust at everything...
Obsessions are recurrent, intrusive thoughts, impulses, or images

that are perceived as inappropriate, grotesque, or forbidden .
Obsessions that cause anxiety and significant clinical discomfort
are called "non-self" or "ego-dystonic" because their content is
very different from the thoughts that the person usually has.
Anxiety disorders
CAMPUS
UNIVERSITY
Obsessions are perceived as uncontrollable, and the sufferer often fears that he or she will lose
Anxiety disorders
CAMPUS
UNIVERSITY
control and may act on such thoughts or impulses. Common themes include contamination
with germs or bodily fluids, doubt (that is, worry that something important has been
overlooked or that the victim has unknowingly caused harm to someone) , order or symmetry,
or loss of control of violent or sexual impulses.
Compulsions are repetitive behaviors or mental acts that reduce the anxiety that
accompanies an obsession or "avoid" some event that happens . Compulsions include overt
behaviors, such as washing hands or checking, and mental acts such as counting or praying. It is
not uncommon for compulsive rituals to take long periods of time, even hours, to complete.
For example, hand washing, intended to alleviate pollution anxiety, is a common cause of
contact dermatitis [a common skin disease].
Although previously considered rare, Obsessive Compulsive Disorder has been
documented to have a 1-year prevalence of 2.4%. Obsessive Compulsive Disorder is equally
common in men and women.
Obsessive-Compulsive Disorder typically begins between adolescence and adulthood
(men) or in young adults (women). Approximately 20 to 30% of people in clinical samples with a
diagnosis of Obsessive-Compulsive Disorder have a history of tics, and approximately a quarter
of these people meet the criteria for Tourette's Disorder.
Obsessive-Compulsive Disorder has a clear hereditary pattern and somewhat greater
specificity than most familial Anxiety Disorders. Additionally, there is an increased risk of
Obsessive-Compulsive Disorder among first-degree relatives with Tourette Disorder. Other
mental disorders that could fall into the spectrum of Obsessive-Compulsive Disorder are
Trichotillomania (compulsive hair pulling), Compulsive Theft, Gambling, and Sexual Behavior
Disorders.
We are beginning to understand some of the brain activities associated with OCD. The
caudate nucleus (a part of the basal ganglia near the limbic system) is responsible for, among
other things, impulses, including things like reminding you to close doors, brush your teeth,
wash your hands, and so on. It sends messages to the orbital area (above the eyes) of the
prefrontal area, which tells us that something
Anxiety disorders
CAMPUS
UNIVERSITY
not well. It also sends messages to the cingulate gyrus (just below the frontal lobe) , which
keeps attention, in this case, on the feeling that something is not right and that something
needs to be done. It is believed that in people with OCD, this system is stuck on "high alert."
It should be noted that OCD responds quite well to the same medications (such as
Prozac) that help people who are depressed, suggesting that serotonin pathways in the frontal
lobe and limbic system are involved, as is the case with Depression. . More recently, scientists
have discovered several genes that appear to be strongly linked to OCD.
But I don't think OCD is a purely physiological disorder! It varies greatly from one
culture to another. In some cultures, the behaviors are still seen as positive. Remember that
there are still all kinds of superstitious behaviors that people engage in today, which are no
different from compulsions. And, at the same time that being obsessed with, for example,
germs is considered strange, being obsessed with, for example, football is considered perfectly
normal in our culture!
Types of OCD
^ Those who wash or clean themselves . Obsessions focus on pollution, dirt or similar topics.
There may be fear of catching a disease or it may occur in the form of thoughts. A whole
series of ritualistic behaviors are launched, such as washing hands X times, disinfecting
them with certain products, etc. As a result of these behaviors, dermatological problems
may appear. It is not strange that these people ask their family members to carry out
similar “detoxification” behaviors.
^ Those who check: This type of behavior focuses on checking so that a catastrophe does not
happen: checking that the gas cylinder is closed, the heater is off, etc. For fear of being
robbed, they can also check that the doors and windows are closed.
e) Those who tidy up : These people consider it essential that everything be ordered or
arranged in its place. They usually look for symmetry.
^ Those who repeat: Obsessions focus on the fact that a catastrophe is going to happen,
usually that loved people have an accident or suffer an illness.
Anxiety disorders
CAMPUS
UNIVERSITY
5 Those who accumulate : Obsessions are related to the fear of throwing away something
important that they may need in the future. Compulsions consist of accumulating, storing,
and keeping objects that normally make no sense to keep.
^ Those who make sure not to do harm : Obsessions refer to harming certain people or
oneself, especially helpless people, children or the elderly. They can appear in an
imperative form (“hit him”) or in the form of a question (“What if I threw it out the
window?”) . These types of thoughts cause very intense discomfort, as well as great guilt.
Within this type of obsession is that of sexually assaulting a person, in response to which
the person acts by not having contact with them. Within this category the impulse to
commit suicide can also be included.
In these types of OCD, physical neutralization behaviors are normally used, although
covert, reassurance or distraction rituals also occur. Normally, the following behaviors usually
occur:
^ Those who mentally restore : The most characteristic example is that of people whose
obsessions are in the form of blasphemy, although there is also the fear of being
homosexual.
^ Those who mentally check : they are those who fear specific catastrophes, such as suffering
a robbery, a flood... These types of people mentally check that potentially dangerous
situations are safe.
^ Those who mentally repeat : To get rid of the fear that encompasses them, they will
mentally repeat phrases or words.
^ Those who seek symmetry : The obsession is related to finding bodily perfection. The ritual
is usually to compare, looking at each other, touching and measuring the areas of their
body.
^ Those who perform actions slowly : The obsession is achieving perfect execution.
^ Those who try to answer philosophical or intellectual doubts.
^ Those who try to prove that they are not deceived: They suffer from jealousy, although not
all jealousy appears in the form of OCD.
Anxiety disorders
CAMPUS
UNIVERSITY
Related Disorders
Anxiety disorders
CAMPUS
UNIVERSITY
Example: Hello. Since I got mononucleosis this summer and got sunstroke, I
became a hypochondriac. I had been so sick before and although I am in good
health, when I feel a little weak I become obsessed and can even get worse
and have tachycardia; On top of that, I got sick once because, apart from
being a hypochondriac, I'm photophobic, and when I went to Burger King and
the lights I got dizzy and nervous and I almost fainted. I'm worried all day because I'm very
afraid...
We could also include Hypochondria here (even though it is

"officially" a Somatoform Disorder). People with Hypochondria
(called Hypochondriacs) are troubled by the fear of having or
contracting a serious illness . Even after being told that they do not
have the disease they are worried about, they continue to worry.
They often exaggerate minor abnormalities, go from doctor to
doctor, and order repeated examinations and medical tests. An estimate of the prevalence of
Hypochondriacs is that it is between 4% and 9% of the population.
A curious version of Hypochondria is found in India, called dhat. People with dhat suffer
from anxiety, fatigue, pain, weakness, depression, etc. - all around an obsessive worry about
losing too much semen! . We may laugh, but 100 years ago, Westerners also believed that a
man has semen only to the extent that he uses it in his lifetime, and 50 years ago, coaches
warned their players not to have sex the night before an important match, as it could leave
them without energy. It is not much different from those who, in the US today, are obsessed
with aging to such a degree that they are willing to undergo surgery and poison injections to
look younger ! Even though these activities They can actually reduce their lifespan!
Anxiety disorders
CAMPUS
UNIVERSITY
There are three other disorders related to Obsessive-Compulsive Disorder5

(although officially they are in the category of Impulse Control Disorders):
• Trichotillomania is the " recurrent pulling out of hair for pleasure,
gratification or relief of tension, which causes significant hair loss ." It
is not limited to the hair on the head, and even eyelashes can be
pulled out. Trichotillomania is
often associated with stress, but sometimes occurs while the person
is relaxing as well.
It usually begins in childhood or adolescence. Between 1 and 2% of college students
reported having had Trichotillomania at some point. The students I have known who suffer
from Trichotillomania also suffer from OCD.
• Kleptomania is the “ recurrent failure to resist impulses to steal objects that are not essential
for personal use or monetary value .” The person knows that he is
wrong, he feels the fear of being captured, and he feels guilty about
it, but he can't seem to resist the urge. It is rare, but much more
common among women than men. It is, as you can imagine, difficult
to differentiate from theft!
intentional!.
Pathological Gambling is " a maladaptive, recurrent and persistent
gambling behavior ." We often call it Compulsive Gambling. It is
accompanied by a lot of distorted thinking - superstition,
overconfidence, denial. Pathological gamblers tend to be high-energy
people who get bored easily, and the urge to gamble increases when
they are under stress.
5 Depending on the professional, you can choose one classification or another. The important thing is not so much
the “label” but the treatment to improve the patient's quality of life.
Anxiety disorders
CAMPUS
UNIVERSITY
This may be 1 to 3% of the population, and two-thirds are men.
DISORDER INTERVENTIONS
Anxiety disorders
CAMPUS
UNIVERSITY
Agoraphobia ^ Procedures for exposure to avoided or

feared situations.
Simple Phobia ^ Exposure procedures to phobic stimuli.
Social phobia ^ Procedures of Restructuring

cognitive, Relaxation-Desensitization,
Training in Social Skills and exposure to
social situations.
Panic Disorder ^ Slow Relaxation Procedures, Techniques
Vagales, Exposure
Interoceptive and Cognitive Prevention.
Obsessive-Compulsive Disorder ^ Procedures for exposure to underlying fears

and Cognitive Therapy with vulnerability
schemes.
Anxiety Disorder ^ Cognitive Therapy Procedures, Generalized
Relaxation and exposure to feared
activities.
Stress Disorder ^ Procedures of exposure to

memories and posttraumatic signs,
Cognitive Restructuring Therapy and
Stress Inoculation.
TREATMENT OF ANXIETY DISORDERS6
6 The description of the content of the Treatment sessions for each of the Anxiety Disorders is merely informative
(guidance); as well as the rhythm of the sessions, since this will be imposed by how the patient progresses.
Anxiety disorders
CAMPUS
UNIVERSITY
Although in Anxiety Disorders there are

questionnaires that are general for all types
of disorders, such as the ADIS-V that allows
evaluating Panic Disorder, Agoraphobia,
Social Phobia, Avoidant Personality
Disorder, Generalized Anxiety Disorder,
Obsessive-Compulsive Disorder, Specific
Phobia, Post-Traumatic Stress Disorder,
Major Depression, Disorder
dysthymic,
Alcohol Abuse/Dependency
Substance Abuse/Dependency, there are
specific questionnaires and scales for each type of disorder, since each one will require
guidelines to be diagnosed. Therefore, below, the questionnaires used in each of the disorders
will be presented.
Diagnostic Algorithms
Anxiety disorders
CAMPUS
UNIVERSITY
Patient with signs /

symptoms of ANXIETY
Consider ADAPTATION disorder \

_____________-________________)
Mental disorder due to

PHYSICAL ILLNESS
ALCOHOL DRUG use

disorder
Consider another mental

disorder PSYCHOTIC 0
DEPRESSIVE \_________________
_____________,
PRIMARY ANXIETY DISORDERS
Worry about
Reexperience Fear of objects or Obsessions or Sudden attacks of everything and
traumatic event situations compulsions anxiety or fear multiple somatic sad mood
complaints
T () f\ 1
Consider POST-
(N Consider Consider MIXED
Consider PHOBIC Consider GENERAL
TRAUMA STRESS DISORDER Consider PANIC ANXIOUS-
ANXIETY ANXIETY
DISORDER OBSESSIVE DISORDER DEPRESSIVE
DISORDERS DISORDER ZADA
TICO COMPULSIVE DISORDER
J \ l
.
OR .
l _____
Source: Modified from: Pascual PascualP,MllenaFererA, Morena Rayo S.Tcte LapeiraJ. MEipaoenteanioso.ntemetj. Fistemra.com; 2005.
Anxiety disorders
CAMPUS
UNIVERSITY
Anxiety disorders
CAMPUS
UNIVERSITY
Anxiety disorders
CAMPUS
UNIVERSITY
PANIC DISORDER (PANIC DISORDER)
1. DIAGNOSTIC GUIDELINES FOR DSM-V PANIC DISORDER

2. THE COGNITIVE MODEL OF PANIC DISORDER: THE CLARK MODEL (1988).
It is fundamentally an attributional
model. The patient applies a
cognitive scheme to the bodily
sensations experienced. about
threats
potential (loss of control, heart
attack, He drowned,
become
crazy...etc.),so that
cognitively distorts the
threatening value of such
catastrophic automatics); those interpretations sensations (thoughts

catastrophists increase the level of
anxiety and the initial bodily sensations, which are again interpreted in a catastrophic way
(vicious circle), until the apprehension increases to a level in which hyperventilation occurs,
a decrease in carbon dioxide, an increase in the PH in the blood, which triggers the panic
attack.
COGNITIVE MODEL OF PANIC DISORDER
Learning History and Biological Factors (1)------------- Cognitive Schemes (2)

o Threats: loss of personal control, heart attack, drowning, going crazy, etc.
Anxiety disorders
CAMPUS
UNIVERSITY
Internal and External Stimuli Activators (3)------------------------ Cognitive Distortions (4)

o Catastrophic vision (apprehension of harm).
o Minimization: of its prediction and control.
Anxiety disorders
CAMPUS
UNIVERSITY
RESULTING INTERACTIVE CIRCLE (5)
Thought-----------------------------Affect/Physiological Activation----------------Conduct.
Catastrophic interpretations. Distress. Behavioral immobilization.
Increasing apprehension of sensations.
Increase in associated body sensations.
Selective attention to bodily sensations. Avoidance of situations.
Vegetative symptoms.
Hyperventilation.
CO2 reduction.
Increase in blood PH.
3. THERAPEUTIC OBJECTIVES. They are similar to those of Generalized Anxiety Disorder,

but adapted to this disorder:
5 Reduction in the frequency and intensity of panic attacks.
^ Reduction of associated avoidance behaviors (if they appear).
^ Acquisition of coping skills and prevention of panic attacks.
^ Identification and modification of distortions and threatening-catastrophic
assumptions.
Disorders of A
CAMPUS
UNIVERSITY
Disorders of A
CAMPUS
UNIVERSITY
4. EVALUATION QUESTIONNAIRES. The most commonly used questionnaires for the

evaluation of panic are usually self-registrations that include a list of common panic
symptoms that the patient rates as present or not present and/or the intensity with which
they appear. As in the CT of other disorders, these records are completed with the typical
type of Self-Registration used (Situations-Emotional State-Thought-Behavior). To point out
two types of Questionnaires-Self-registrations, we mention:
1) Rapee's Panic Attack Record (1990):
• Name:
• Date:
o Time: _______________ Duration (minutes):___________________________
• With:
Master in Psychology General Sanitary............................................................................1
INDEX........................................................................................................................2
JUSTIFICATION.......................................................................................................9
INTRODUCTION....................................................................................................10
DESCRIPTION OF ANXIETY DISORDERS........................................................23
DESCRIPTION OF DISORDERS RELATED TO STRESSORS AND.................37
TRAUMATIC EVENTS..........................................................................................37
DESCRIPTION OF OBSESSIVE-COMPULSIVE DISORDERS..........................44
Types of OCD.......................................................................................................47
TREATMENT OF ANXIETY DISORDERS..........................................................53
Thought Affect/Physiological Activation Conduct...........................................60
1) Personal identification data:...........................................................................69
2) Reason for consultation:................................................................................69
3) Symptoms:.....................................................................................................69
4) History of the problem and previous treatments:...........................................70
Anxiety disorders
CAMPUS
5) Personal
UNIVERSITY and family history:..........................................................................71
^ Evolution data-results:.....................................................................................72
Personal Assumptions. Practice through homework assignments........................79
5) Cognitive-Behavioral Alternatives to Unspoken Rules.................................79
A) BEHAVIORAL TECHNIQUES:...............................................................79
B) COGNITIVE TECHNIQUES:...................................................................80
3) Symptoms:.....................................................................................................81
4) History of the problem and previous treatments:...........................................82
5) Personal and family history:..........................................................................82
^ Session 1:.......................................................................................................100
= Session 2:.........................................................................................................101
^ Session 3:.......................................................................................................102
> Session 4:.........................................................................................................102
^ Session 5:.......................................................................................................102
^ Session 6:.......................................................................................................102
= Session 7:.........................................................................................................102
^ Session 8:.......................................................................................................103
= Session 9:.........................................................................................................104
^ Session 14:.....................................................................................................104
= Session 15:.......................................................................................................104
3) Symptoms:...................................................................................................122
4) History of the problem and previous treatments:.........................................123
^ Session #1:.....................................................................................................123
^ Session #2:.....................................................................................................126
^ Session #3:.....................................................................................................126
^ Post-Treatment:.............................................................................................126
4) Modification of the Assumptions Personals who do vulnerable to the.......138
> Session #1:.......................................................................................................147
> Session No. 2:..................................................................................................147
> Session No. 3:..................................................................................................147
• Situation. In literature class talking about astrology with some classmates.....147
> Session No. 4:..................................................................................................148
■ . Situation: At the pub, a girl asked me to sit with her.................................148
^ Results:..........................................................................................................151
(idem to previous section)...................................................................................160
1) Personal identification data:.........................................................................161
Anxiety disorders
CAMPUS
3) Symptoms:...................................................................................................162
UNIVERSITY
5) Personal and family history:........................................................................162

^ Session #1 to #8:............................................................................................165
> Session #12 to #30:..........................................................................................165
> Session #30 to #45:..........................................................................................165
Semee'ad )...................................................................................................................167
EMER- -a....................................................................................................................167
1) Evaluation and conceptualization of problems :..........................................193
2) Therapeutic socialization:............................................................................194
1. Same as above with obsessions and.............................................................196
4. Typical rules for response prevention:.........................................................196
4. Treatment of associated Anxiety-Depression problems .............................198
Obsessive Fears (Downward Arrow) Alternatives..........................................199
1) Identification data :......................................................................................199
2) Reason for consultation:..............................................................................199
3) Symptoms:...................................................................................................201
4) History of the problem and previous treatments:.........................................202
5) Personal and family history:........................................................................203
> Session #1 and #2:...........................................................................................205
> Session No. 3:..................................................................................................205
> Session No. 4:..................................................................................................205
> Session No. 5:..................................................................................................205
> Session No. 7:..................................................................................................205
= Session No. 8:..................................................................................................206
F Session No. 10:................................................................................................206
^ Session #11:...................................................................................................206
^ Session nº13:..................................................................................................206
^ Session #14:...................................................................................................208
F Session No. 15:...............................................................................................208
^ Session #16:...................................................................................................208
^ Session #17:...................................................................................................208
1) Functional-Cognitive or Psychological Exploration:..................................221
2) Information Techniques (Cognitive Reconceptualization):.........................221
5) Treatment of Anxiety and/or Associated Depression 15 ..............................222
7) Exposure to phobic fears of death and/or illness :.......................................222
DIFFICULTIES IN EVALUATION......................................................................223
PHARMACOLOGICAL TREATMENTS.............................................................226
Anxiety disorders
CAMPUS
BASIC RULES
UNIVERSITY FOR THE PREVENTION OF ANXIETY AND STRESS
18
PROBLEMS ........................................................................................................229
1. The diet:.......................................................................................................229
2. Rest:.............................................................................................................229
4. Organization:...............................................................................................230
5. Problem Solving and Decision Making:......................................................230
6. Interpretation of situations and problems:...................................................231
Attributions and Self-esteem:..............................................................................231
8. Relationships with others (partner, friends, colleagues, family, etc.):.........232
9. Specific Training in Anxiety and Stress Control Techniques:....................232
DSM-5. MODIFICATIONS REGARDING THE DSM-IV-TR............................233
BIBLIOGRAPHY...................................................................................................234
o Chest pain/pressure ( ).
either Sweat ( ).
either He drowned ( ).
either Blasts of heat/cold ( ).
Anxiety disorders
CAMPUS
UNIVERSITY
o Sleepy or tingling limbs ( ).

o Fear of dying ( ).
o Fear of going crazy ( ).
o Fear of losing control ( ).
o Fear of: (write)__________________________________________________
2) Scale for the Evaluation of Phobias, Panic and Generalized Anxiety by Cottraux and
collaborators (1995). It has a subscale referring to the main panic symptoms that the
patient evaluates in intensity from 0 to 8 and their presence (YES/NO).
5. THE INTERVENTION PROCESS. The therapist usually goes through a list in his intervention
that goes from explaining to the patient what a Panic Disorder is to modifying the
catastrophic meanings in the presence of the eliciting stimuli:
^ Evaluation: It basically consists of detecting panic responses (cognitive, affective,
physiological and behavioral) , eliciting internal and external stimuli and associated
automatic thoughts-meanings (eg fear of going crazy). Three types of automatic
catastrophic thoughts are usually detected:
o Vulnerability ("I am weak...").
o Escalation ("Once it starts it gets worse").
o Lack of control ("I can't help it").
^ The vicious circles of their panic attack are explained to the patient, placing special
emphasis on catastrophic cognitions, concentration on internal sensations, and lack
of respiratory control.It is usually useful to induce a little hyperventilation (eg through
rapid breathing, holding your breath for a minute, using negative thoughts, etc.) to
show what was explained. Likewise, it is usually useful to present the difference
between psychosis and panic attack (since the fear of madness is common).
^ Learning Cognitive-Behavioral Techniques to modify vicious circles and their cognitive
basis. Rehearsal in consultation and practice at home: Basic Cognitive Prevention
Technique.
Anxiety disorders
CAMPUS
6. UNIVERSITY
INTERVENTION TECHNIQUES.
Anxiety disorders
CAMPUS
UNIVERSITY
6.1. COGNITIVE TECHNIQUES:

> Reattribution of internal sensations : The patient learns to look for more realistic
explanations for his initial negative interpretations (eg "It is not a heart attack but a
symptom of anxiety.")
> Decatastrophization: The patient questions his negative predictions based on
evidence ("Other times I thought I was dying and it didn't happen").
6.2. BEHAVIORAL TECHNIQUES:

1. Distraction: Relaxation Training, visualization of pleasant scenes, stopping and
changing thoughts, distraction with external stimuli...
2. Sensory Focus: Learning to pay attention to pleasant internal sensations (eg
through Relaxation, meditation, etc.).
3. Respiratory Control: Gradual exercises to increase abdominal breathing.
4. Educational Indications: For example, the "ten rules for dealing with panic" by
Mathews et al.: stay in place, sit, breathe slowly, teach yourself to calm down, etc.
5. Exposure: Imagining the eliciting internal sensations, the associated cognitions and
meanings and/or increasing respiratory disturbance (eg rapid breathing or
voluntary respiratory arrest).
The basic technique combines cognitive and behavioral elements and is Cognitive
Prevention:
1. With eyes closed, the patient is induced to imagine feeling the eliciting internal
sensations (eg dizziness, tachycardia, etc.) and external (eg "Being in the square").
2. Added to this imagination is the self-induction of personal negative cognitions ("I'm
going to have a heart attack", "I'm going to die", eg).
3. The task can be increased by asking the patient at regular intervals to hold his
breath or make it faster.
4. Self-instructions on decatastrophication, retribution, respiratory control, and
prevention of escape responses can be included at the end.
Anxiety disorders
CAMPUS
UNIVERSITY
5. Steps 1 to 4 (temporary exposure intervals) are gradually increased until the

patient manages them (reducing his evaluative anxiety pe on a scale of 0 to 100).
6. The patient can practice at home in calmer moments. It is fundamentally about
preparing for attacks (getting used to and disconfirming catastrophic and
uncontrollable internal and external stimuli).
7. Assessment of medication support (eg first phases).
7. CLINICAL CASE (Author. J.J. Ruiz Sánchez).

7.1. CLINIC HISTORY:
1) Personal identification data:
- 15 year old woman. Single and 2nd Bachelor student.

- Referred by the family doctor.
2) Reason for consultation:
- For the past 2 months she has been feeling nervous, with a feeling of suffocation. A
week ago he again felt a sensation of suffocation and tightness in his chest,
breaking down into tears in that situation. She wakes up abruptly with her muscles
contracted, being unable to move at that moment, becoming very distressed.
- He adds that he is very sensitive to arguments between his parents, and also feels
inferior to his sister in terms of studies. Her parents continually compare her to
that one, and she feels angry for thinking that they are treating her unfairly. On the
other hand, he says, parents are very busy with their work and "they don't pay any
attention to me."
3) Symptoms:
- Cognitive:
- He believes that his family pays little attention to him.
- Apprehension: expectation of dying from drowning ("Catastrophic Vision").
- He believes himself inferior to his sister ("Personalization").
- Nightmares regarding death and the dead (acquaintances, family members).
Anxiety disorders
CAMPUS
UNIVERSITY
- Affective :
- Periods of anger.
- Constant anxiety.
- periods of sadness, passengers.
- Occasional crying.
- Fear of death and todie.
- Motivational:
- Fear. Expectations of dying.
- Behavioral:
- Compulsive laughter (for No cry).
- Wake up scared after nightmares.
- Cry with difficulty.
- Motor restlessness.
- Avoid talking to your family about your problems.
- Repeat course. He doesn't see this as a problem.
- Physiological:
- "Spontaneous" feeling of drowning.
- Chest pain.
- Abdominal pain.
- Muscle immobility.
- Dyspnoea.
- Abrupt-anxious awakening.
- Paresthesias in hands and feet.
4) History of the problem and previous treatments:
- She says that her problem began 2 months ago following the unexpected death of
a young neighbor who she knew from a heart attack. This made him remember his
grandmother's death from a heart attack, and that's when his "suffocation" attacks
began. The tension and arguments that her parents have over work also make her
nervous.
- The family doctor prescribed Trankimazin and Marcen, and the patient initially
Anxiety disorders
CAMPUS
improved until she relapsed into "drowning" again.
UNIVERSITY
Anxiety disorders
CAMPUS
UNIVERSITY
5) Personal and family history:
- This year he has repeated 1st Baccalaureate and has failed mathematics. Menarche
at 13 years old. No previous treatments (except from the GP). No relevant
psychological and physical history.
- Lives with parents and sister: Father 45 a. baker. Mother 45 a. housewife and sister
from 18 to. wants to study nursing in another city. Lately, there are frequent
arguments between parents regarding the expansion of the bakery and related
expenses.
6) Diagnosis: Panic Attack Disorder (T. Panic).
7.2 FUNCTIONAL-COGNITIVE ANALYSIS AND CONCEPTUALIZATION OF PROBLEMS:

> Two problems are conceptualized:
- Panic crisis.
- Family relationships: "Jealousy" of the sister and "lack of affection" of the
parents. Related anxiety state.
- The following are detected as internal and external situations involved in anxiety
crises:
- Memories of well-known people who have died of a heart attack.
- Interpret feelings of anxiety as an alarm that you are drowning.
- Expectations that it will get worse and not improve.
- It is detected as external and internal situations of relational problems and
associated general anxiety:
- Comparisons of parents with respect to their sister.

- Witness parental discussions.
- That her mother asks her who she has been with, what she has done ("She
thinks she is watched and controlled").
Anxiety disorders
CAMPUS
-
UNIVERSITY
"My mother doesn't listen to me and she should." “He has me in his grip.”
Anxiety disorders
CAMPUS
UNIVERSITY
- "I'm a zero to my parents compared to my sister."

> Hypothesis: Parental problems, relationships with them (non-assertive), memories of
death, their assessment of "injustice" and "comparative personalization" generate a
state of general anxiety, on which the patient applies a threat scheme ( Fear of
dying from a heart attack) producing anxiety attacks.
7.3. INTERVENTION PROCESS:

^ Session No. 1: Clinical history and evaluation of problems.
^ Session No. 2: Return of the hypothesis. Explanation of the PAC and Self-
registration relationship. Relaxation.
^ Session No. 3: Explanation of the "Catastrophic Vision" and the erroneous
interpretations or attributions of bodily sensations. Cognitive Prevention: as a
basic task between sessions and Self-registration of the task.
^ Session nº 4 : Analysis of progress and monitoring of effects of Cognitive
Prevention:.
^ Session nº 5 to 17 : Idem to nº 4 and management of comparative
"personalization" with respect to his sister, anger management and cognitions
of "injustice": changing automatic thoughts and role-playing-modeling-
behavioral rehearsal of various modalities of assertive behavior ("Disk
Lined",
"Fog Bank", etc.).
^ Evolution data-results:
SESSION NO. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
BDI 10 9 9 10 7 7 6 5 7 7 3 2 0 0 0 0 0
EAZ 46 45 43 44 45 42 44 42 42 44 42 26 29 28 31 27 22
Crisis No. 3 4 2 4 1 2 0 4 1 4 2 0 0 0 0 0 0
Intersessions
^ Note: 21 points is the minimum score on the EAZ
Anxiety disorders
CAMPUS
UNIVERSITY
5 Results: The crises had disappeared, the patient did not attribute them to a heart
disease but to her erroneous expectations, she believed herself capable of
managing her anxiety and she was more assertive with her family and others.
AGORAPHOBIA
1. DIAGNOSTIC GUIDELINES FOR AGORAPHOBIA BY THE DSM-V-7 .

2. COGNITIVE MODELS OF AGORAPHOBIA: THE BECK MODEL AND THE MODEL OF
GUIDANO AND LIOTTI (1985).
The cognitive construct of Agoraphobia is based on
personal vulnerability imposed by cognitive
schemes that contain personal meanings referring
to the perception of internal and external danger
(almost always related to the fear of losing personal
control or the appearance of a
acute and sudden illness that threatens life) and another personal meaning related to the
previous one, referring to the need to have the security and support of others in case the
feared thing happens. When the patient is alone, away from people who provide security,
or in places where sources of security are difficult to access (eg elevators, tunnels, moving
buses, etc.) cognitive schemes are activated, producing distorted processing of information
("Catastrophic Vision"-anticipation of health dangers, mental or emotional disorder, etc.)
and developing avoidance behaviors to those "situational cues" related by the patient to the
perceived danger and lack of access to sources of security. This disorder would have
consequences for the patient, such as a loss of self-confidence due to their dependence on
others and multiple self-criticisms due to their perceived inability (negative self-
assessment). Likewise, derived cognitive conflicts would appear, fundamentally the fear of
loneliness and the dependence-independence balance (control) in interpersonal
relationships.
7 Consult the link “Diagnostic Criteria for AD” (DSM-V) in the Resource Guide.
Anxiety disorders
CAMPUS
UNIVERSITY
Likewise, it would be pointed out that agoraphobic cognitive schemes would derive from
childhood fears.
The Guidano and Liotti Model differs from the previous one in reversing the order and
hierarchy of the cognitions involved. For these authors there would be two cognitive levels :
a more explicit (conscious) cognitive level referring to the causal attributions maintained by
the patient about what happens to them, and to the expectations regarding their state.
Basically it refers to the patient's idea of having an illness that can suddenly appear and the
anticipated consequences of its possible appearance (fear of going crazy, suffering a heart
attack, etc.). The basic meanings identified by Beck and Emery are placed at this level. On the
other hand, there would be a deeper or tacit level (more unconscious or abstract) that would
contain two basic rules of action for the patient. These rules
They would imply the patient's obligation to avoid
loneliness and the obligation to maintain control
of situations. The patient would have problems
verbalizing and detecting these rules ("making
them conscious") and would mistakenly attribute
their anxiety to suffering from an illness with an
unpredictable onset. The origin of the difficulties
in converting tacit knowledge to explicit
knowledge must be sought in Bowlby. The development of an "anxious attachment" to
parents and the alteration of emotional ties (separation, loss) would be found at the origin of
agoraphobic cognitive organization.
In a schematic way we reproduce below the main points of the cognitive functioning of
the agoraphobic .
Anxiety disorders
CAMPUS
UNIVERSITY
COGNITIVE MODEL OF AGORAPHOBIA
Personal Learning History and Biological Factors (1) ------------- Cognitive Schemes (2)
Alterations in early emotional bonds.
"Anxious" type attachment. Threats to physical and emotional health.
Fear of not being able to access security sources.
Separations and emotional losses.
Rules for avoiding loneliness and

the need for interpersonal control.
Believing you have a disease.
ACTIVATING PHOBIC SITUATIONS (3)--------------- COGNITIVE DISTORTIONS (4)
^ Solitude: absence of a close environment, of a company in whom one can trust (eg
being alone in a public place).
^ Catastrophic vision.
^ Maximization of danger and minimization of safety.
^ Restriction on personal control or freedom of movement (eg traffic jams, elevators,

crowded places, public transport vehicles that cannot be abandoned when desired,
etc.).
RESULTING INTERACTIVE CIRCLES (5)

Thought ----------------------Keen--------------------Conduct
Apprehension Anxiety Avoidance
Search for safety, medical care, etc.
Anxiety disorders
CAMPUS
3. UNIVERSITY
THERAPEUTIC OBJECTIVES . As in other Phobic Disorders, it would be treated
basically from:
Anxiety disorders
CAMPUS
UNIVERSITY
5 Reduce or eliminate agoraphobic avoidance behaviors (avoidance of certain situations

and the need to seek security or company to cope) and the anxiety associated with
them.
^ Acquisition by the patient of cognitive-behavioral skills to cope with phobic situations.
^ Modification of the cognitive base that makes the patient vulnerable to agoraphobic
disorder (Distortions and Cognitive Schemes) through Cognitive-Behavioral Techniques.
4. EVALUATION QUESTIONNAIRES. We refer to some examples of questionnaires used to

evaluate the agoraphobic problem:
1) Phobia, Panic and Diffuse Anxiety Evaluation Scale (Cottraux, 1990): Contains a
subscale that allows evaluating the panic component of the disorder (See section on
Panic Disorder).
2) Agoraphobic Cognitions Scale (Chambles et al. 1984): The patient rates on a scale from
1 (That thought never appears ) to 5 (I think about it all the time) the frequency of
appearance of a list of 14 types of frequent agoraphobic cognitions (e.g. "I'm going to
faint", "I'm going to go crazy", "I'm going to act ridiculous").
3) Panic attacks: Symptom Assessment Sheet (Salkovskis, 1989): It is a list of 28 items
referring to typical symptoms of a panic attack. The patient rates their perceived
intensity (From 0 - Not at all bothersome to 4 - Very bothersome or intense).
5. INTERVENTION PROCESS. We use the model of Beck and Emery and Guidano and Liotti to
present the intervention process. The first three steps would be common to both models,
and the last two to the Guidano and Liotti model:
1) Evaluation and Conceptualization of problems. Through Functional/cognitive Analysis,
the avoided situations-cognitions involved and avoidance and safety strategies used
would be detected; as well as a hierarchy of internal and external situations and
associated degree of anxiety.
Anxiety disorders
CAMPUS
UNIVERSITY
2) Therapeutic socialization: Explanation of therapy to the patient, thought-affect-

behavior relationship and Self-registration.
3) Cognitive Behavioral Alternatives to Vicious Circles, Distortions and Personal
Assumptions. Practice through homework assignments.
4) Detection of Tacit Rules: Through three procedures-Definition of the interpersonal
context where the first symptoms arose, search for cognitive-affective-behavioral
patterns consistent with the explicit level (erroneous attributions) and cognitive analysis
(meaning) of the resistance presented to cognitive interventions -behavioral.
5) Cognitive-Behavioral Alternatives to Unspoken Rules.
6. INTERVENTION TECHNIQUES. We can group the intervention techniques according to

whether they are aimed at modifying panic attacks or modifying agoraphobic avoidance
behavior:
6.1. MANAGEMENT OF PANIC ATTACKS:
A) BEHAVIORAL TECHNIQUES:
1) Relaxation Training: It is aimed at reducing background anxiety states (not
panic anxiety). The Jacobson (Progressive Muscle Relaxation) or Schultz
(Autogenic Relaxation) methods are usually used. The patient is trained in the
Relaxation sequences and can practice them at home.
2) Respiratory regulation: The patient is taught to slow his breathing to 8 10
respiratory cycles per minute, regulating it with the help of a metronome. It
should be shallow breathing to avoid increasing alkalosis, which would
aggravate the symptoms. Once the patient has learned to manage breathing in
the manner described, he is induced to produce voluntary hyperventilation (eg
rapid breathing, respiratory endurance, etc.) and to control it through
respiratory regulation. In this way the patient has an inoculation technique.
3) Vagal Techniques: The Valsava baro-sinus reflex is usually used. The patient is
asked to produce abdominal hyperpressure of three to five
Anxiety disorders
CAMPUS
UNIVERSITY
seconds. This is done by swelling the belly, which produces a rapid reduction in
heart rate. This maneuver can be repeated a dozen times. It is used together
with in vivo exposure together with respiratory regulation in patients with
cardiac fears.
B) COGNITIVE TECHNIQUES:
1) Descending Arrow: Starting from automatic thinking (Expectation of Threat or
Catastrophic Vision) the patient wonders about the consequences until
reaching the underlying personal assumption. Once detected it can be tested
(eg Automatic thought: "I'm going to lose control" - Consequence: What would
happen if it happened? - Response: "I would be considered crazy by people and
my family" - Consequence: What would happen if it happened? - Response: "I
would be considered crazy by people and my family" - Consequence: What
would happen if it happened? - Answer (Postulated/Assumed): "I must be in
control of situations and avoid them so that I don't have a panic attack, be
hospitalized, and be disapproved of by the people who know me").
2) Exposure in the imagination plus retribution and cognitive discussion: A
sequence of the type can be carried out: 5 minutes of Relaxation - 5 minutes of
exposure in the imagination - 5 minutes of hyperventilation and retribution of
sensations - 15 minutes of breathing for respiratory regulation and - 10 minutes
of discussion about the process and its use as a preventive task (Cognitive
Prevention).
6.2. MANAGEMENT OF AGORAPHOBIC AVOIDANCE BEHAVIORS: The avoided situations

are prioritized and exposure is used with them (eg first in imagination, then live); It is
sometimes used in combination with stress inoculation.
7. CLINICAL CASE (Therapist: AT Beck. Adaptation: J. Ruiz).

Anxiety disorders
CAMPUS
UNIVERSITY
1) Identification data: Single man, 29 years old. Stopped for a year.

2) Reason for consultation: You feel nervous and sad. He spends almost every day
at home, watching television, smoking, and trying to avoid confrontations with
his sister, who, according to the patient, dominates the house with her
tantrums, unpredictable behavior, and exaggerated demands. The patient's
main fear is vomiting after eating, creating confusion and angering his sister.
This has caused him to restrict his meals, lose weight and avoid eating with his
family members for five months. His fear of vomiting in front of others leads
him to seriously limit his social life, seeing only his neighbors and not making
any appointments. He is also afraid of moving away from home and getting lost,
which has led him to increasingly restrict the distance he is able to move from
home.
3) Symptoms:
• Cognitive:
- Thoughts about losing control and vomiting in front of others, making
them angry.
- Thoughts regarding leaving home and getting lost.
- Lack of decision.
- Finding yourself unable to work while you have anxiety.
- Fear of being sexually approached in public while people were
watching: Fear of sexual requests from women.
• Affective:
- Anxiety (anxiety predominates).
- Sadness.
- Motivational:
- Desires to avoid situations where you think you may vomit or be sexually
approached.
• Physiological:
Anxiety disorders
CAMPUS
UNIVERSITY
- Weight loss (mild).
Anxiety disorders
CAMPUS
UNIVERSITY
- General muscle tension.

• Behavioral:
- Avoidance of assertive statements in front of family and strangers.
- Phobic behaviors (moving away from home eg).
• He has been in treatment with three therapists previously because of his

anxiety. Last year he had been medicated with Xanax, Delmane and Llavil,
with no relevance to his sadness and anxiety.
• His history of anxiety dates back to his childhood and he had been
hospitalized five times since childhood for "nervous stomach." During a
hospitalization, according to the patient, pieces of food were removed in
his intestine. His anguish had prevented him from eating in front of others,
working, and traveling far from home.
• He lives with his parents and an older sister.

• His sister has a "hysterical" behavior, dominating the house with her
tantrums, unpredictable behavior, and unreasonable demands. The patient
is afraid of making her angry if he vomits while eating in front of her.
• The patient describes his parents as "overprotective", they did not let him
spend the night with friends or relatives, like the other children, and they
discouraged him, even when he was young, from the idea of moving to his
own apartment to live, due to his lack of furniture, telling him "if you can't
do things completely right, don't do them."
6) Diagnosis: Agoraphobic Disorder.
7.2. FUNCTIONAL-COGNITIVE ANALYSIS AND CONCEPTUALIZATION OF PROBLEMS:

The first sessions focused on obtaining a list of problems, informing the patient
about anxiety, and performing cognitive and functional analyzes
Anxiety disorders
CAMPUS
UNIVERSITY
of anxiety-evoking situations. The list of problems obtained in the first session included
: a) being unable to eat due to anxiety, b) lack of decision, c) avoidance of bars,
restaurants, parties and shopping trips, d) being unable to work cause of anxiety. There
were automatic thoughts associated with those problems.
The thought associated with being unable to eat was, "I'm nauseous, I'll throw up,
and I'll make a fuss." In terms of lack of decision it was "I quit when I feel terrible." The
avoidance of bars, restaurants and the like was due to the idea of vomiting in front of
others, making them angry and, as a consequence, marginalizing him; as well as being
sexually approached by a woman while others were watching. Her thoughts about
being unable to work were along the lines of " I can't do a good (perfect) job until I
have freed myself from anxiety" and were related to messages from her mother that if
she couldn't do something well she wouldn't. did it.

^ First sessions:
• The first problem to be addressed was food. The patient was taught to
record his thoughts before eating, these were usually negative predictions
("my sister is going to come and she will be angry"). He was also instructed
to eat when he was hungry, chewing each bite fifteen times, and leaving his
fork on his plate in order to slow his rapid intake of food. In this way, he
worked behaviorally to reduce the probability of bothering, and cognitively
to test negative predictions. He was also informed of the difference
between organic symptoms and anxiety symptoms, so that he would know
the difference, and not confuse emotions as a sign of organic disease. This
helped him reduce his negative predictions.
Anxiety disorders
CAMPUS
UNIVERSITY
• The volitional nature of the patient's vomiting became evident when

exploring with him the meaning of this act. He said, "I've been sick all my
life and everyone told me there was something wrong with me... to prove
that this was physical, to show that I was sick, I would throw up."
• The patient was instructed in alternative ways to achieve relief from

anxiety including telling himself "This can't go any further," breathing
slowly, and distracting himself from physical sensations. He replaced the
Relaxation exercises with the attitude of joking. As he demonstrated
competence on the graded tasks assigned, he increasingly avoided
situations and relied less on these behaviors. It was also clear that the
patient avoided activities that his parents chose for him. The assertion
training in the last sessions helped him make his own decisions and carry
them out without using the role and illness behaviors.
• Acting contrary to the "I am a sick person" scheme was a powerful tool. To
help him do this, he was asked to use self-instructions ("I'm kidding", "I
don't have to vomit"), to list times when he did not behave like a sick
person (e.g. doing odd jobs, taking care of himself, observing the anxiety
levels and seeing their fluctuations classifying their nausea as a sign of
anxiety and not of physical illness).He was also assigned tasks gradually
designed to increase his activity outside the home (e.g., accepting
carpentry jobs from his neighbors, having coffee at a neighborhood bar),
reducing his agoraphobic avoidance (e.g., increasing travel distances), and
decreasing their lack of decisiveness by completing tasks in an affordable
manner (e.g., enrolling in a community college, calling to make an
appointment).
• His lack of decision was also addressed in the sessions working with his
automatic thoughts "I can't do anything until I stop."
Anxiety disorders
CAMPUS
UNIVERSITY
be fine" . This thought led him to avoid calling the school manager to
arrange an interview. In the therapy session he telephoned another co-
therapist who acted as if he were in charge of the school in a very
believable way. Before this role-playing, the patient was asked to rate his
anxiety on a measure from 0 to 100 (he scored 70), to notice his thoughts
("I will be too nervous to talk"), and to predict his success from 0. to 100.
After the role-playing, he evaluated both the co-therapist's credibility in his
role as school manager (he gave it a 100) and his anxiety during the role-
playing (he gave it a 20).
• This combination of cognitive and behavioral techniques helped him reduce

his anxiety in this practical situation and allowed him to contact the school
manager and attend school the following week.
^ Latest sessions:
• The last sessions focused on the independence and autonomy of his family.
He was able to cognitively and imaginatively repeat scenes with his sister in
which he repeated to himself in each attempt at an argument "you must be
right." The work on assertiveness began with his thoughts about acting out
for himself ("it's not nice to confront a family member") and continuing with
questioning the assumption that being assertive is harmful, also listing the
advantages and disadvantages of acting in one's own interest before the
family, and behavioral repetition (assertive essays). He found it useful to
carry two cards. In one was the automatic thought “mom says I won't do it
right” with the adaptive response “opinions are not facts” on the flip side.
On the other card was the message "my parents exaggerated how
dangerous the world is."
^ Results : The patient stopped taking Elavil and Dalmane in the fourth session of
Cognitive Therapy and rarely took Xanax (psychotropic drugs with a commercial
name in the US). Currently he is doing very well at school, he eats quietly in the
school cafeteria, drives to school, and interacts with his classmates. He
Anxiety disorders
CAMPUS
UNIVERSITY continues to test his negative predictions and
Anxiety disorders
CAMPUS
UNIVERSITY
has a good attitude towards accepting risk: "It's the only way to make
progress."
APPROXIMATE SCHEME OF THE DEVELOPMENT OF THE TREATMENT SESSIONS

- PANIC DISORDER
The Cognitive-Behavioral Programs for the treatment of this disorder have been
structured as follows:
• Psychoeducation.
• Relaxation and Breathing Training.
• Cognitive Restructuring.
• Interoceptive and in vivo exposure to feared bodily sensations.
• Behavioral experiments.
^ Psychoeducation . The first phase of the treatment program consists of offering the patient
a clear explanation of how a panic attack occurs, explaining the following sections (Botella
and Ballester):
• What is anxiety?
• Adaptive value of anxiety.
• Absence of harmful consequences of anxiety for the body.
• Ways of anxiety manifesting.
• Central importance of thought in triggering anxiety.
• Presentation of the cognitive model of panic.
• Relaxation and breathing training.
Anxiety disorders
CAMPUS
UNIVERSITY
The aim of this technique is to

attenuate the patient's physiological
activity, but great care must be taken with
how it is used, since it can become a
safety behavior, since it would prevent
the patient from confronting to feared
situations.
The Relaxation method that Pastor
and Sevilla propose is Deep Muscle Relaxation, which involves learning to discriminate the
sensations of tension and distension that our muscles adopt. The technique would be the
following:
1) Prior preparation: It is advisable that the exercise be done in a quiet place, without
excessive light and free of noise. Avoid having tight clothing or footwear, as well as
watches or bracelets that fit. Don't do it after meals, wait at least two hours after each
meal to do it. Sit in a comfortable chair or couch, or lie on a sofa or bed on your back,
with both arms parallel to your body. If you do it sitting, place your feet flat on the
floor, your hands on your buttocks and leave your shoulders as low as possible, close
your eyes while doing the exercise (although if you have any difficulty, you can leave
them open, although in this case it is It is advisable that you look at an object or
painting that is nearby). Also remember that until you have a certain mastery over
Relaxation, do not apply it in situations where you are very nervous, as you could fail
and become demotivated too soon. Just like when someone is learning to play tennis, if
they play with someone more expert they will lose, and it is desirable that you go step
by step, do the same with Relaxation; Do not apply it to difficult situations, at least until
you have adequate control of it.
2) Exercise : “ Close your eyes (you can leave them open if you are more comfortable).
Start by inhaling the air through your nose and direct it towards the lower part of your
belly, do not release it, but count slowly mentally 1 2 3, and release the air
gently
Anxiety disorders
CAMPUS
UNIVERSITY
between his lips.
Anxiety disorders
CAMPUS
UNIVERSITY
Repeat this breath four more times. Now let's begin to go through the main
muscles of the body that can be put into tension and begin to release the tension
accumulated in them. We start with the head. Raise your eyebrows as far up as you can
................................................. Keep them up.............................. Notice the annoying
and unpleasant tension that occurs in your forehead, temples and areas near your
nose... Notice the annoying tension....... Now gently, slowly drop your eyebrows back to
the starting position.................Notice how pleasant it is to release that tension...
Breathe in through your nose towards your lower belly, hold the breath............. count
slowly 1... 2... 3... Now release the air gently between your lips and mentally repeat the
words to yourself...................... ”Quiet. .Relaxed”......................... Continue breathing
like this for about four more times... Now press your eyelids tightly against your eyes...
Notice the annoying and unpleasant tension that occurs in the eyelids, eyes and the
area near the nose and forehead... annoying and unpleasant tension................. Now
gently release those muscles... notice how the tension disappears... how nice it is to
release it.
Breathe air through your nose into your lower belly again. hold your breath... count
slowly in your head...................................................................................... 1 2 3,
........................................................................release the air gently between
your lips, and repeat thinking the words “Calm down.”..........Relaxed.......”. You are
becoming more and more calm............................more relaxed...continue breathing this
way for about four more times............................. now open your nostrils
as much as you can... notice the annoying tension in the bridge of the nose, the cheeks...
annoying and unpleasant tension... keep it................ and now gently release that
tension........... free yourself from it Notice how nice it is to have those muscles loose
and relaxed....Inhale air through your nose towards your lower belly, hold it, count... 1
.......................2....................3........ AND....................release it gently between your lips
....................... thinking about the
words............... “Quiet......... Relaxed”....... continue breathing this way four more times
......................... Now pull the corners or ends of your lips, as if forcing a smile, as much
Anxiety disorders
CAMPUS
UNIVERSITY
as you can........ hold that tension... notice how unpleasant it is... The tension in your
jaw and lips...... And now, gently... let go. . notice how pleasant it is to release that
tension............. Breathe deeply as directed............ taking air through your nose
towards the lower part of your belly..........
Anxiety disorders
CAMPUS
UNIVERSITY
count from 1 to 3 slowly and release it gently between your lips, repeating the words
“Calm/Relaxed” repeat this breath four more times... Now firmly clench your upper
teeth against your lower teeth.................................... keep them tight
.......................................now release them, get rid of the tension accumulated in that
area................................enjoy the state of increasing relaxation.....................................
repeat yourself mentally. ……………………… breathe as
you have been doing...... repeat yourself
.......................................mentally…………………….........
“Quiet............Relaxed”................ AND now tilt
head forward as much as you can...............................
keep it there................................................................ notice tension in the neck, throat
and neck...annoying tension........................................ that now you gently release
.................................................................................... “Quiet And Relaxed”
Breathe in through your nose toward your lower belly. accounts 1 2
....................................................................................3 AND you release it gently
between your lips........................................................ you keep repeating
this breath four times more................... AND now you tilt your head back all
As much as you can............ Hold it like this for a moment, notice the uncomfortable
tension in your neck and neck........................... now let go....................... Return your
head to its initial position...free yourself from tension...............................”Calm and
Relaxed”............... breath deeply...................... count to three and release the air
between your lips. Now continue raising your shoulders
up as much as you can... notice the tension in that area...annoying tension that you are
now going to release...release yourself from the tension..........”Quiet................ Relaxed”
...................... you breathe deeply the same way..................... repeat the Breath four
more times.... and now bend your elbows as much as you can notice the tension in that
area............... release the tension...................... Leave your hands on your buttocks.......
you have freed yourself from the accumulated tension............ ”Quiet............... Relaxed”
Anxiety disorders
CAMPUS
UNIVERSITY
...................... breathing....................................deep and calm

how are you doing it.......... Repeat it four more times................. and now. . Press the
chest out,...breast out notice the tension in that area...
area have zone...annoying tension If
tension bothers Release the accumulated tension
”Quiet Relaxed” you free yourself from
tension And you breathe slowly and
deeply And you repeat this breath four
more times gently you are becoming more
and more relaxed now.........pulls the stomach in
Everything you can........ notice the tension in that area.... annoying tension......... That
Anxiety disorders
CAMPUS
UNIVERSITY
now let go................ you free yourself from tension.......................................... ”Calm

and Relaxed”............ you breathe deeply........... four times more...................... Now
raise your right arm like
if you hit the front with a closed fist..................... notice tension in the shoulder, elbow,
forearm, hand, palm and fingers................... release that tension................ slowly drop
your hand towards your buttock.................... you free yourself from tension ”Calm and
Relaxed”.................. Deep breathing............ the air towards the lower part of the
belly... counts... 1...2...3... And you release it gently between your lips.......... you repeat
this breath four times.................................... And now do the same with the left arm
................................ You raise it forward, with your fist closed..................... Annoying
tension in the shoulder...elbow, forearm...wrist, hand...fingers And now you release
that tension... you get rid of it “Calm down... Relaxed “... you breathe deeply... and
repeat that breath four more times............... Now raise your right leg.......... everything
that
you can. . and pull the tips of your fingers inwards............... as if you wanted to touch
your knee with your toes....................................................... annoying tension that now
you let go.............................................................................. you free yourself from it
“Calm…and Relaxed”… deep breathing becoming calmer and more relaxed You repeat
that breath four more times................................................. now
lift your left leg in the same way................................. I sew if you wanted to touch your
knee with your fingers... pulling the instep towards the knee. annoying tension....... that
now you release... leaving the leg fall gently.................
”Calm/Relaxed”... Slow, deep breathing................................................... enjoy a
complete state of relaxation and tranquility.................................. Relaxation.................
tranquillity................................................................. Relaxation tranquillity................
you.......................................................you have done it yourself
andwith practice it....................you will do
better and.....better tranquillity......................
Anxiety disorders
CAMPUS
UNIVERSITY
Relaxation............................................................................................................ And
now
slowly....................................... Take air through your nose........................... toward
................................................................the
lower abdomen............................................................. And releases it gently for you
mouth............................................... each every time you do it you will count from 10
to 0........................................................................
Anxiety disorders
CAMPUS
UNIVERSITY
......................................................10...............................................9......................8......
....................................... 7............................... 6.................................... 5..... Opens
.................................................the
eyes........... 4 ....................................... 3.............................. 2............................... 1......
You can join....................the exercise is over.
Once you have learned the Relaxation of the 16 muscle groups, you will learn to reduce it
to 8 and later to 4 muscle groups to make its application easier. In addition, this will also allow
the patient to later perform Mental Relaxation, in which they will already be familiar with the
sensations of tension and Relaxation. From this moment on, you can start using it in everyday
situations.
Another technique to control physiological activation is deep breathing. For Panic-
Agoraphobia Disorders, it is especially indicated in those who present hyperventilation,
although it will also be useful in the rest. The way to proceed is: sit comfortably, with one of
your hands on your chest and the other on your abdominal area; Inhale gently and slowly
through the nose, noticing how the lungs fill with air and the stomach part comes out. The air
must be kept inside for 2-3 seconds and then slowly expelled through the mouth, until there is
nothing left inside. To practice, this cycle must be performed about 4-5 times.
^ Cognitive Restructuring. With this technique, the aim is to identify the irrational ideas or
thoughts that the patient presents regarding the disorder and subject them to reasoning to
check whether they are true or not. To do this, first of all, they must have been recorded in
a Self-Registration, which will be where we can extract these ideas and see in which
situations they occur. When discussing the catastrophic thoughts that the patient has, a
series of considerations must be taken into account.
1. Define negative thinking : That the patient knows how to identify the thought he
has when he suffers the crisis.
2. Evidence for and against that thought : Once the thought has been identified, the
reasons that lead to thinking what is true must be analyzed. He
Anxiety disorders
CAMPUS
UNIVERSITY
In this case, the therapist will have to ask questions to check why the patient thinks
these series of things.
3. Analyzing the probabilities of that thought happening : It involves rationally

carrying out an analysis of the probabilities of what the patient fears so much
happening, for example, considering it on a scale from 0 to 100.
4. Alternative interpretations : When the patient recognizes that there is a possibility
that he is making a mistake, then the possible alternatives that may exist to that
thought are worked on.
5. Decatastrophization: At this moment it is about discussing what would be the
worst thing that could happen to him if that thought were really what he thinks.
6. Utility of thought : in this step, the patient is induced to think if what could happen
to him/her were true, what usefulness is there in thinking about it all day.
^ Interoceptive and live exposure. Once the person evaluates that the feared situation does
not carry any danger and has Relaxation techniques, it is time to face those situations, for
which exposure therapy will be used. To do this, first we will have to explain how the
anxiety graph works, how when we face a feared situation, anxiety rises to a point, where
it remains, and then begins to go down and finally disappears.
The first exposure is usually the longest, since the person is not trained and is not an
expert in handling these situations.
The way to expose oneself to the sensations that the person feels is interoceptive
exposure, where those sensations that the patient fears and that will end up causing the panic
attack will be voluntarily created.
To reproduce feared situations, the following situation can be
taken as an example: When the person is afraid of losing control or
going crazy, this usually appears because the patient finds himself in a
Anxiety disorders
CAMPUS
UNIVERSITY
feeling of unreality, in which he can even see "little lights." ”. In this case, to reproduce the
attack you can start by hyperventilating. Once this is done, the person must
Anxiety disorders
CAMPUS
UNIVERSITY
Fix your eyes on a strong light for approximately 30 seconds and then look away abruptly,
keeping your eyes wide open. A similar exercise is to do the same as the previous one but when
looking at the light, close and open your eyes. The last exercise can be in a dark room, turning
the light on and off continuously for about 2 minutes.
With all these exercises, the person simulates the factors that usually occur when he has
the thought that he is going to go crazy.
Once the exposure to interoceptive sensations has been carried out, it is the turn of the
live exposure. First of all, it is advisable for the patient to make a list of the feared situations or
activities. Then you will choose the situation that causes you the least anxiety or for which you
are most motivated.
When you face the situation you will have to stay in it knowing that your anxiety will
decrease at a given moment. In the meantime, you can use cognitive techniques, as well as
Relaxation and breathing techniques. It is very important that you do not use escape or
avoidance techniques during exposure. Once finished, it is recommended that you write down
on a record sheet what your anxiety level has been, what thoughts you have had and what
techniques you have used.
Exposure sessions must be carried out frequently and of sufficient duration to produce
habituation.
^ Behavioral Experiments. Some of the exercises that can be performed as behavioral

experiments are:
• Focus of attention: On many occasions patients tend to be hypervigilant regarding

the bodily sensations they suffer. Continuing with the example, of the thought of
fear of suffering a heart attack, an exercise to do will be to close your eyes and for
5 minutes focus on your heartbeat. The patient will realize that this focusing means
that he can feel the beats in various parts of his body. When you open your eyes,
you will be asked to stop focusing on the heartbeat and explain the sensations you
have had, comment on the possibility that it is you, during the panic attacks, who
Anxiety disorders
CAMPUS
UNIVERSITY
Increase your heart rate by focusing your attention on them.
• Overingestion of caffeine : As an arouser, caffeine causes

activation and nervousness. If the patient ingests a greater
amount of caffeine than he is accustomed to, it can
generate sensations similar to those that occur during a
panic attack, which would demonstrate that these
sensations can be generated by other means.
TREATMENT SCHEME8
^ Session 1:
• Welcome and summary of the therapy format.
• Number and frequency of sessions.
• Fee.
• Confidentiality.
• Commitment to therapy: Attendance at sessions, participation in exercises,

homework.
• Basic rules for sessions.

• Beginning of the evaluation.
• Administration Clinical Interview.
• Homework: Self-registrations.
= Session 2:
• Assessment. Administration Clinical Interview. It is very important to record what

the last crisis was like (situation, body sensations, thoughts and behavior), also ask
about: other situations in which crises have occurred; situations or activities
8 This treatment scheme is indicative, since the order and pace of the therapy will depend on the patient and how it
develops. This same Treatment Program can be applied to other Anxiety Disorders, since most use similar techniques.
Anxiety disorders
CAMPUS
UNIVERSITY
avoided for fear of a crisis of
Anxiety disorders
CAMPUS
UNIVERSITY
distress; reaction of the patient and other people to the crisis; existence of crisis
modulators; onset and course of the problem, perceived cause of the disorder, etc.
^ Session 3:
• Assessment. Test Administration.

> Session 4:
• Return of information.
• Treatment plan proposal.
• Homework: recording panic situations.
^ Session 5:
• Psychoeducation: Explanation of the following questions: What is anxiety?;

adaptive value of it; absence of harmful consequences of anxiety for the body;
manifestations of anxiety (modes of response); cognitive model of the panic attack;
hyperventilation test.
• Homework: Recording panic situations.

^ Session 6:
• Clarification of doubts regarding the Psychoeducational Module.
• Relaxation/Breathing Training (depending on what the therapist considers most

appropriate).
• Homework: Practice of the learned technique and recording of sensations.

= Session 7:
• Relaxation/Breathing Training.
• Clarification of doubts and questions regarding them.
• Homework: Practice the techniques learned and record sensations.
Anxiety disorders
CAMPUS
UNIVERSITY
^ Session 8:
• Cognitive discussion of the catastrophic interpretations of the most frequent bodily

sensations in crises (we know them through the records you have made at home).
Anxiety disorders
CAMPUS
UNIVERSITY
• Homework: Recording thoughts in crises.

= Session 9:
• Cognitive discussions of catastrophic interpretations.

• Behavioral experiments (such as focus of attention or overeating).
• Homework: Recording crisis thoughts.
e Session 10:
> • Exposure to internal and external stimuli, through carrying out the
corresponding hierarchy.
e • Homework: Record the exposure situation.

> Session 11:
• Exposure to internal and external stimuli, through carrying out the

> Session 12:

> Session 13:
• Homework: Record the exposure situation.

^ Session 14:
• Relapse prevention: Review of previous sessions, reinforcement for efforts made,

patient expectations regarding crisis situations, practice of learned techniques.
= Session 15:
• Relapse prevention: Final assessment of therapy, review of issues and techniques

learned.
Anxiety disorders
CAMPUS
•
UNIVERSITY
Location for future follow-up appointments.
Anxiety disorders
CAMPUS
UNIVERSITY
EXPLANATION OF ANXIETY
The problem that worries you and for which you mainly come for consultation is hot
flashes and hot flashes. These hot flashes are one of the symptoms in which what we call
“anxiety” can manifest.
Anxiety is neither more nor less than a response of our body, which occurs when faced
with dangerous or challenging situations and which prepares us to fight or flee. For example :
• When you are walking down the street and around the corner a thief attacks you and asks
for everything you are carrying. At that moment your body reacts by becoming active
(becoming anxious) and you notice symptoms such as tachycardia, sweating,
tremors,...that way you can face it or run away. After a short time this activation will
decrease.
• “When your father kicked you out of the house for not giving him the money because he
spent it on the machines” — In that challenging situation you reacted by confronting him
thanks to the anxiety or activation of your body. You also had symptoms such as hot
flushes, cold sweats, tachycardia,… It is a normal response that all human beings have.
When the body is activated or we become anxious, the sensations we notice are various:
- Palpitations.
- Sweating.
- Muscle tremor.
- Sensation of choking.
- Heats.
- Chest pains.
- Difficult breathing or choking.
- Dizziness
- Fear of losing control or going crazy,…
The person in charge of activating our body and producing these symptoms is the
Autonomous Nervous System that acts:
- Pumping blood faster (that's why you feel hot and turn red).
Anxiety disorders
CAMPUS
UNIVERSITY
- Increasing breathing to provide more oxygen.

- Dilating the pupils to expand the field of vision,…
Almost at the same time, the Parasympathetic Nervous System comes into operation,
which acts by reducing the activation created by the Autonomous Nervous System, meaning
that the excessively high anxiety will not last long (although it may seem like an eternity).
On the other hand, we also need a certain degree of activation to carry out daily
activities such as cleaning the house, going to work, cleaning the elderly, changing the beds,...
The problem occurs when you become anxious in situations that you believe are
dangerous or challenging and that in reality are not. The situations that you mistakenly see as
dangerous are:
- Places full of people.

- Fear of what others may think of you.
- Fear of your own physical sensations.
- Fear of strange thoughts that you don't know why get into your head.
- Heated sites,...
This happens to you through “association”, that is, when you have encountered a
dangerous or unpleasant situation, for example; When the wife of the man you were caring for
accused you of having relations with him - You became active and noticed, among other things,
heat, negative thoughts, suffocation,... but this heat can also occur due to other circumstances,
for example from making an effort, from air conditioning,…So these new situations that cause
heat remind you of the others where you also had it and trigger the rest of the symptoms.
Physical exercise
Air-conditioning
Public speaking
Anxiety disorders
CAMPUS
UNIVERSITY
This is how your problem originates, but what is maintaining it is the fact of escaping
from the situation every time it occurs when anxiety is at its highest. That way you learn that
escaping solves the problem, while if you stay it could increase more and more.
Now you know that when anxiety is high, it always ends up decreasing.
Anxiety disorders
CAMPUS
UNIVERSITY
— Anxiety Cycle
EXAMPLE OF DISCUSSION OF AUTOMATIC THINKING

“I'm going to have a heart attack and I'm going to die” (Taken from Pastor and Sevilla)
T: Based on the scientific data you already have, is it possible that you might have an
attack?
Q: Well, everyone could have an attack, but it is unlikely, since the data
Doctors indicate that my heart is
healthy and that I do not suffer
from any physical disorder that
would increase the likelihood of
suffering a heart disorder. The
chances I have of it happening to me are the same as the rest of the people.
T: How many times have you feared this and how many times has it actually happened to
you?
Q: I have feared it hundreds of times, but it has never happened to me, which is why I am
beginning to believe that the probability is zero.
T: How could you explain what you are feeling in real terms?
Q: Now I know perfectly well. The discomfort I notice, including tachycardia and chest pain,
are caused by my anxiety and I confuse these sensations with the symptoms of a heart
attack.
Anxiety disorders
CAMPUS
T: Does thinking that I'm going to have a heart attack help me overcome panic?
UNIVERSITY
Q: Not at all, on the contrary, it provokes it in me.
Anxiety disorders
CAMPUS
UNIVERSITY
- T: Does thinking this help me feel good and act effectively?

- Q: No, it makes me feel terrible and causes me to run away.
ALTERNATIVE INTERPRETATIONS
E9 One of the main fears that people have is that they will have a heart attack.
E9 Many people believe that anxiety can cause heart attacks, but this is completely false, since
for this to happen, a series of organic variables must exist, along with other factors such as
age or lifestyle.
E9 Panic produces an increase in the heart rate, since when we are anxious the heart
accelerates to send more blood and oxygen to the tissues and muscles, therefore, these
increases in the heart rate do not damage the heart, but instead they make stronger.
TEN RULES TO DEAL WITH PANIC

(Mathews et al., 1986)
1. Remember that the sensations experienced are nothing more than an exaggeration of the
body's normal reactions to stress.
2. They are not, at all, harmful or dangerous. Only unpleasant. Nothing worse will happen.
3. Stop adding to your panic with frightening thoughts about what is happening and where it
could lead.
4. Notice what is happening in your body right now, not what you fear might happen.
5. Wait and give the fear time to pass. Don't fight against it or run away from it. Just accept it.
6. Notice that when you stop adding to it by adding fearful thoughts, the fear begins to
disappear on its own.
7. Remember that the goal of the practice is to learn how to face fear without avoiding it.
Therefore, this is an opportunity to progress.
8. Think about the progress you have made so far, despite all the difficulties. Think about how
satisfied you will be when you get it this time.
Anxiety disorders
CAMPUS
UNIVERSITY
9. When you start to feel better, look around you and start planning what to do next.
10. When you are ready to continue, start in a calm, relaxed way. There is no need for effort or
hurry.
ACCEPTANCE OF SENSATIONS
The instructions given are taken from Barry Stevens, with modifications that
fundamentally include a much greater emphasis on passivity and making no movements or
avoidance of sensations that come to consciousness. The specific instructions given are the
following:
"Position, lying with knees bent and feet resting on the floor. The knees can be placed
together if you are more comfortable or apart if you prefer.
It is about focusing on the most unpleasant sensation we have and getting in touch
with it. Remain in contact as if you were a light source that does not push or force anything and
does not leave anything as it is. It is about making friends with our sensations, seeing what they
are like and how they evolve on their own without our intervention. Letting the sensation evolve
as it wants, if something hurts we let the pain develop, grow or decrease without intervening.
Since it is an unpleasant sensation, we automatically tend to try to make it decrease and
disappear, now we have to let it grow, if that is its natural evolution. Contact lightly, let the
sensations guide our consciousness, let's not try to feel what we want but rather what the body
tells us. We are going to observe the sensation, see its characteristics, which part of the body is
involved, if it is sharp, dull, if it is always the same or changes over time, etc. The most
important thing is to observe without intervening. If any other sensation becomes stronger than
the one we have contacted, we go to it. Let's let all the unpleasant sensations come to our
consciousness.
Avoid conscious movements since they generally try to make unpleasant sensations
disappear. We are going to work from passivity. If any involuntary movement arises, let it occur
passively as well.
Anxiety disorders
CAMPUS
UNIVERSITY
The partner must be very attentive to their own body, relaxing any tensions that appear
and also attentive to what happens to their partner, they must be present but without
intervening in the process. From time to time the person who is working will inform you of what
they are feeling, how they are going and what is happening with the sensation they are
experiencing. The person who helps must encourage you to continue with the sensations and
maintain them without trying to eliminate them.
If someone does not find any unpleasant sensations, let them begin to feel the sensations they
have in the head and then in the neck and travel throughout the body, letting the sensations fill
their consciousness without intervening."
CLINICAL APPLICATIONS OF PASSIVE ACCEPTANCE OF SENSATIONS

There are some cases in which this acceptance of bodily sensations is essential. The
clearest is that of hypochondriacs who interpret some of the bodily sensations they feel as
threatening and try to avoid them. One task of therapy is exposure to the sensation in a way
that accepts it without giving a flight response from it.
The goal of this work in therapy is passive acceptance of bodily sensations. The
proposal presented here has been carried out with hypochondriacs with very positive clinical
results. In reality, a flood is carried out on bodily sensations that are interpreted by patients as
a trigger for a heart attack, stroke, loss of control, etc. The sensation remains until it fades.
Clark establishes the theory of the causal link between bodily sensations that are
misinterpreted and catastrophically and panic attacks. The proposed work is an exposure to
sensations and learning another way to behave when they feel them. When it is done, the
automatic reaction and avoidance of unpleasant sensations is cut.
In Relaxation Training, paradoxical reactions have been reported in which the subject's
anxiety increases. This work is also an aid to deal with anxiety induced by feelings of relaxation.
Other theoretical frameworks in which the instructions that have been proposed can be
inscribed are:
Anxiety disorders
CAMPUS
UNIVERSITY
• It is a technique of flooding the most unpleasant sensation you have and just by
mentioning it, the one you are avoiding usually appears, which is interpreted as a heart
attack, pain, etc. The stimulus that is maintained is the sensation itself and the instruction is
given to eliminate all avoidance behaviors, specifically movements, remaining completely
still and paying attention to the sensation. By suggesting that only the relaxation response
be given, if one is capable of giving it, any avoidance response is eliminated and the
mechanism that leads to extinction or inhibition of the sensation is favored. The person has
been taught to be more stoic. Instead of engaging in overt behavior and avoiding
threatening or unpleasant sensations, the child is taught to give a passive response of
acceptance and relaxation, which is more appropriate in many cases.
• Within Lazarus' classifications of coping strategies, action inhibition can be included. In this
way, pain avoidance behaviors are inhibited. Passive acceptance can give rise to a
phenomenon similar to the habituation of responses that occurs in flooding.
• The method coincides with the technique that Turk calls somatization and which has been
shown to be effective in the treatment of pain. It focuses on the body from a distance,
without intervening and becoming aware of other sensations in the place. In controlled
studies to relieve pain, Turk's method has been shown to be effective. In the studies cited,
the results have all been positive.
Among the theories that attempt to explain the process by which chronic pain occurs are
those that are based on the fact that in some cases the reaction to pain gives rise to
movements that lead to generating more tension in the painful area that can contribute to
increasing pain, thus entering a vicious circle. Theoretical explanations of this type can be
found in Keefe when mentioning the stress-pain hypothesis and the "pain-muscle_spasm-pain"
cycle. Passive acceptance of sensations can be a good means of breaking this feedback process.
It can also be a good help in any exposure that is carried out since in many cases avoidance
is associated with unpleasant sensations. If the subject accepts his sensations, the exposure will
be easier or shorter.
Anxiety disorders
CAMPUS
UNIVERSITY
SPECIFIC PHOBIAS
IAGNOSTIC GUIDELINES FOR SPECIFIC PHOBIA BY THE DSM-IV-TR 9 .

HE COGNITIVE MODEL OF SPECIFIC PHOBIA: THE BECK MODEL (1985).
The cognitive model of Phobias postulates that phobic anxiety is
associated with a predisposition in the processing of information
regarding the danger-threat that a certain object or situation implies.
It is not the object, event or situation that the patient fears, but the
anticipation of the consequences that the situation may have.
For example, a patient with a phobia of doctors and hospitals had had a traumatic incident in
he office. Her doctor had made an incision in her throat before she was fully anesthetized and her fear of
Consult the link “Diagnostic Criteria for AD” (DSM-IV-TR) in the Resource Guide.
Anxiety disorders
CAMPUS
UNIVERSITY
hospitals was directly related to the belief that, despite being under the
doctor's care, she could have stopped breathing.
It is important to consider the specific cognitions
associated with the anticipation of consequences. The
same phobic situation may not evoke the same thoughts
and images in different individuals. This predisposition
constitutes danger schemes in specific situations and can
develop from traumatic experiences, social modeling or phylogenetically prepared fears. This
cognitive scheme would be related to a series of cognitive distortions:
^ Arbitrary Inference-Catastrophic Vision: The patient anticipates the occurrence of
threatening events in a given situation, without having evidence for it.
^ Overgeneralization: The patient, starting from a situation where he anticipates a
threat, relates other similar situations where similar threats could occur, all without
sufficient evidence.
^ Maximization-Minimization: The patient exaggerates the dangers of the situation and
undervalues the safety elements of the situation or his or her ability to cope with it.
^ Personalization: The patient compares himself to when he did not have that fear and
his current avoidance or dependence on others to overcome it, criticizing himself for
it (more common in Social Phobias than in Simple Phobias).
Below we represent the model:
COGNITIVE MODEL OF SPECIFIC PHOBIAS

Learning History and Biological Factors (1)--------------------- Cognitive Schemes (2).
• Anticipated threats to certain situations.
SPECIFIC ACTIVATING SITUATIONS (2)------------------- COGNITIVE DISTORTIONS (3).
• Catastrophic Vision.
• Overgeneralization.
• Maximization/Minimization.
Anxiety disorders
CAMPUS
UNIVERSITY
• Personalization.
Thought (Apprehension)------Affect (Anxiety, Fear)-----------Behavior (Avoidance, Flight)
3. THERAPEUTIC OBJECTIVES.
^ Ensure that the patient stops experiencing anxiety regarding the phonic situation.
^ Get the patient to expose himself to the avoided situation and not avoid it.
^ Get the patient to modify his or her anticipatory cognitions regarding the phobic
situation.
4. EVALUATION QUESTIONNAIRES. We will mention only three of the questionnaires used in

the evaluation of Phobias because they represent typical prototypes of those most
frequently used:
1) The Wolpe and Lang Fear Questionnaire (1964): It consists of 122 items referring to
different potentially phobic objects and situations that the patient evaluates from 1 (no
discomfort) to 5 (very much). The therapist groups the responses and conceptualizes
the fears to the core.
2) Cottraux's Phobias, Panic and Generalized Anxiety Evaluation Scale (1985): Contains a
subscale referring to Phobias. The patient writes down his two main Phobias and rates
the degree of avoidance associated with each one from O (I do not experience any
discomfort and I never avoid it) to 8 (I experience extreme discomfort and I always
avoid it).
3) Behavioral Avoidance Test (BAT) by Lang and Lazowick (1965): The therapist exposes
the patient to the real phobic situation and scores the degree of avoidance on a scale
from 0 to 5.
5. THE INTERVENTION PROCESS. In general terms, it follows the same process as general CT.
However, we highlight the following points:
Anxiety disorders
CAMPUS
1) Evaluation:
UNIVERSITY Fundamentally, it is about detecting the type of phobic situation(s), the
type of avoidance behavior and the mediating cognitive component (anticipations
Anxiety disorders
CAMPUS
UNIVERSITY
negative), as well as the degree of associated anxiety (situational-cognitive-affective-

behavioral components).
2) Patient socialization in the working model: thought-affect-behavior relationship, role
of anticipations and avoidance behavior as a way of not contrasting their predictions.
3) Prepare the patient to face avoided situations and thus be able to modify their
anticipation predictions of negative consequences and lack of control. Role of
"personal experiments."
6. INTERVENTION TECHNIQUES.
6.1. COGNITIVE TECHNIQUES:
^ Distraction: Stopping and changing negative thoughts, use of cards with a list of
positive memories or positive characteristics of the patient.
^ Decatastrophization: Changing negative thoughts, checking evidence and finding
solutions.
^ Stress Inoculation: The therapist identifies the patient's internal dialogues before-
during-after facing the phobic situation and its connection with affect and behavior
in each phase. The therapist suggests alternative steps to modify the cognitions-
affects-behaviors involved in the previous-situational and post-situational phases
and trains the patient in these alternatives, so that he can later practice them.
It basically consists of the choice of relevant self-instructions, Relaxation
response and prevention of the Avoidance response. It is usually started by facing
the phases imaginatively and then directly (most of the time gradually).
^ Identification of Personal Assumptions: The therapist usually uses the so-called
DOWNWARD ARROW to detect the meanings associated with negative
anticipations (eg "I'm afraid of the dark" - And what would happen if you're in a
dark place? - "My breathing stops and I'm afraid of dying"). Sometimes it is useful
to trace the historical origin of those meanings to gain self-understanding and
motivation for change.
Anxiety disorders
CAMPUS
UNIVERSITY
6.2. BEHAVIORAL TECHNIQUES:

^ Relaxation Training: The patient is taught to manage and distract themselves from
their anxiety by learning responses incompatible with anxiety (muscle distension,
adequate breathing, etc.).
^ Exposure Techniques: It is the basic technique for managing simple Phobias. It
consists of prioritizing the phobic situations and exposing the patient to them
(gradually or not, imaginatively and/or in person) so that avoidance responses are
prevented and until the anxiety in them decreases. From a cognitive point of view,
they are presented as "personal experiments" to test catastrophic and
uncontrollable anticipations.
7. CLINICAL CASE (Therapist: Cottraux. Adaptation: J. J. Ruiz).

1) Personal identification data: 19-year-old woman.
2) Reason for consultation: Fear of the presence of birds. This fear (Phobia) is very
disabling because it leads her to have difficulties leaving the house and meeting birds.
She cannot approach a bird less than 5 meters away, and can only quickly pass by a bird
at 2-3 meters.
3) Symptoms:
> Cognitive:
• Interior monologue referring to meeting a bird.

• Assessed unbearability of the previous event.
> Affective: Anxiety/fear of encounter situations with birds.
> Physiological:
• Shaking.
• Tachycardia.
Anxiety disorders
CAMPUS
> Motivational:
UNIVERSITY Desires to escape-avoid.
Anxiety disorders
CAMPUS
UNIVERSITY
> Behavioral: Avoidance. Stay at home.

> She places the beginning of her disorder when she was three years old. His
background highlights that both of his parents had "depressions." She has had
several suicide attempts and lives in a disturbed marital environment. At the age of
3, his mother was admitted to a sanatorium for tuberculosis. She was taken to her
grandmother's house who had chickens. Her cousins chased her with bird feathers,
or excited their chickens against her. She attributes the beginning of her Phobia to
the separation from her mother and this situation experienced at her
grandmother's house.
> At 17 years old she was treated for a serious embolism with an appendectomy.
> Last year she was treated for her Schultz Relaxation Phobia for four months
without any results.
5) Diagnosis : Simple phobia.
7.2. FUNCTIONAL-COGNITIVE ANALYSIS AND CONCEPTUALIZATION OF PROBLEMS :

- The variables involved in Phobia were:
- Situational: encountering birds.
- Cognitive: expectations of harm (being stung by birds) and selective abstraction of
childhood memories (separation from parents and trauma from birds-childhood
memories).
- Affective: anxiety about birds.
- Behavioral: Reduction of anxiety due to avoidance of situations of possible
encounter with birds.
^ Session #1:
• The phobic situation was classified on a subjective anxiety distress scale ranging
from 0 to 100. From this scale, a hierarchy of stimuli was constructed, from
highest to lowest degree of anxiety evoked:
Anxiety disorders
CAMPUS
UNIVERSITY
- 100- Cross a square with birds.
- 101- See "The Birds", a film by A.Hitchcock.
Anxiety disorders
CAMPUS
UNIVERSITY
- 102- Touch a bird feather.

- 103- See a bird less than 5 meters away.
- 80- See a stuffed bird.
- 70- Read an ornithological description.
- 71- See a caged bird.
- 50- Look at a photo of a bird.
- 51- See a bird feather at 15-20 cm.
- 40- See a bird flying.
- 30- See a bird far away in the sky.
- 20- See a plastic bird.
- 10- Hearing the word "bird."
• The Situation-Cognition-Affect-Behavior relationship and the Exposure Technique
were explained. An exhibition was carried out in imagination and then live.
a) Gradual exposure in imagination: After 5 minutes of Relaxation the patient
participated in 15 minutes of exposure in imagination. Two successive
scenes were presented (imagining a black feather 50 cm away without
touching it and imagining picking up a feather and touching it).
b) A live exposure session developed immediately: In agreement with the
patient a pen is placed five feet above the therapist's table. At first
subjective anxiety is 5 (scale from 0 to 8). At 5 minutes the subjective
anxiety was 2.
c) At the end of the session, the therapist and the patient agreed on a home
task : to reproduce the session in imagination, every day until subjective
anxiety decreased by at least 50%.
❖ Note: Although the therapist had constructed a hierarchy of 10 to 100, which

he could have used very gradually (Systematic Desensitization), he finally opted
for an exposure method, starting with high levels of subjective anxiety
(choosing the situation of touching a feather of
Anxiety disorders
CAMPUS
UNIVERSITY
bird). The positive result of the first session made him continue with this
technique.
^ Session #2:
❖ Exhibition in imagination:
- Pick up and touch a pen.
- Put the pen in your bag.
- Initial anxiety: 5
- Anxiety after 10 minutes: 2.
❖ Live exhibition : touching a feather. A pen is placed 2 meters from the patient.
She must get closer and closer to it and put it in her bag. The anxiety is very
high (6, from 0 to 8), she expresses an intense feeling of repulsion, cries and
screams. Then she tells a childhood episode where her cousins chased her with
some feathers to make her cry. She is also afraid that the therapist will throw
the feathers at her (for 20 minutes).
❖ Homework: Simply reproduce the session in imagination.
^ Session #3:
❖ She says she is depressed and nervous but also relieved to have access to the
feared situation. She passed at 10 m. of a parrot in the city. Again the session
consists of an exhibition in imagination followed by a live one to touch a pen
and put it in the bag.
❖ Task for: Carry the pen in your bag.
^ Session #4 to #9: Live exhibition consisting of touching a caged bird. Generalization
tasks: Carry a feather in your bag, cross public squares, have a caged bird at home, and
touch the cage.
^ Post-Treatment:
❖ The patient is seen one month after the last treatment session. Your bird has
died. She always carries a pen in her bag. She doesn't avoid the birds now.
Anxiety disorders
CAMPUS
UNIVERSITY
❖ At 8 months she is checked again, she has two pheasants in her garden, she
goes to the chicken coop. She has seen "The Birds" by A. Hitchcock, but she
hates the horror movies her husband loves so much.
❖ The results are psychometrically evaluated:
DATA PRETEST POSTEST POST-TREATMENT

AT 6 MONTHS
Main phobia (0-8). 8 0 0

Panic. 0 0 0
General Anxiety. 2 0 0
Questionnaires:
• Total phobia. 26 2 0
• Depressive Anxiety. 2 0 0
• MMPI (Minimult). Normal Normal Normal

- SPECIFIC PHOBIAS -
Treatment for these types of disorders includes:

Live and Imaginary Exposure, Applied Stress,
Cognitive Restructuring, Modeling and Response
Prevention. The type of techniques to use will
depend on the case and the phobia to be treated.
Of all the techniques mentioned, the
applied tension has not yet been mentioned in
this chapter, which is applied in the case of phobia of blood, injections and wounds (FSIH), and
whose objective is to increase blood pressure and prevent a possible Fainting.
In the case of modeling, as is already known, it consists of the therapist doing the
behavior first, so that the patient later imitates it. Approximate diagram of the development of
the treatment sessions.
Anxiety disorders
CAMPUS
UNIVERSITY
5 Sessions 1, 2 and 3: Evaluation.

^ Session 4: Return of information, treatment approach and therapeutic objectives.
^ Session 5: Psychoeducation. Explanation of anxiety (curve, adaptive value, etc.). Explanation
of why the phobia persists. Breathing training.
^ Session 6: Breathing training. Cognitive Therapy.
^ Session 7: Cognitive Therapy.
^ Session 8: Exposition in imagination.
^ Session 9: Exposition in imagination.
^ Session 10: Live Exposure.
^ Session 11: Live Exhibition.
^ Session 12: Review of achievements.
This description of the content of the sessions is merely informative, since, for example,
there will be phobias in which it is not necessary to carry out the presentation in imagination;
or on the contrary, in which the exhibition cannot be carried out live and can only be carried
out in imagination. As well as the rhythm of the sessions, since this will be imposed by how the
patient progresses.
In between the sessions, homework is usually sent, such as Self-Records, which will help us
to know in which situations this behavior occurs, as well as the thoughts that the patient has.
Also between sessions, this will be when you will have to practice the exercises that you will
have been taught in consultation, such as breathing and exposure.
Regarding this last technique, Bados proposes that the treatment should be planned based
on the following guidelines :
1. Reach an agreement with the patient on the conceptualization of the disorder and the
treatment to be applied, which must be justified and described.
2. It is advisable, to avoid dropouts, that the exposure be gradual. The exposure hierarchy can
be developed from the beginning or in parts as the intervention progresses.
3. The steps must be specific. All feared/avoided situations or a representative sample of
them should be included.
Anxiety disorders
CAMPUS
UNIVERSITY
4. It should be practiced as frequently as possible, every day if possible.

5. It is advisable that the patient apply the treatment alone
(self-exposure), although in cases of difficult situations or
blockages, the therapist or co-therapist can accompany
them on some occasions, although the patient must
complete two practices alone in the same situation.
6. In the exhibitions in which the patient is assisted by a
partner, this will serve as a model, encouraging him to continue forward, praising him for
his progress and encouraging him to focus his attention on the activity to which he is being
exposed and, if necessary, encouraging him to employ coping strategies.
7. To facilitate self-exposure, therapist and patient must plan in common agreement what it
will consist of, when it will take place, and anticipate possible obstacles. The patient will
make a diary of their tasks that the therapist will review at the beginning of the session.
8. Before each practice, the patient must think about the benefits that performing it will bring
him, focusing on his progress to be reinforced by it and without underestimating it even if
it is very small.
9. It is normal and helpful to experience anxiety during practice, but at a moderate level that
does not interfere with the emotional process of fear signals.
10. The patient should remain in the situation until the anxiety is reduced and the desire to
escape disappears. If you leave the situation before the anxiety has subsided enough, you
should calm down and return to the feared situation as soon as possible.
11. Each step of the hierarchy must be repeated more than once, on the same or different day,
until two consecutive practices are achieved in which the level of anxiety has been
minimal.
Anxiety disorders
CAMPUS
UNIVERSITY
12. Defensive behaviors should be gradually eliminated.

13. If progress stops at a step, you need to find out why. If the step is too difficult, one or more
intermediate steps will have to be found.
14. If a panic attack occurs, the patient will try to stay in the situation until it subsides and then
continue practicing a little more.
Anxiety disorders
CAMPUS
UNIVERSITY
15. It is very convenient for the therapist to show cordiality, empathy, respect and self-
confidence and to provide a climate of trust. It should be firm, but not authoritarian.
16. The effectiveness of the exposure is increased by the instructions that generate these
expectations, taking into account that very positive but unrealistic expectations are very
counterproductive.
SOCIAL ANXIETY DISORDER
1. DIAGNOSTIC GUIDELINES FOR SOCIAL PHOBIA BY THE DSM-V10 .

2. THE COGNITIVE MODEL OF SOCIAL PHOBIA: THE BECK MODEL (1985).
The patient would have developed cognitive schemes
referring to threatening meanings and values about being
disapproved, criticized or rejected for his or her actions in a
social situation. These schemes would be activated in social
situations and produce cognitive distortions such as:
5 Catastrophic Vision: The patient selectively maximizes
and abstracts in an anticipatory way the potential danger of the social situation (eg
rejection, criticism) without having evidence for that prediction.
^ Maximization: The patient underestimates or forgets his strategies for managing social
situations. You may also underestimate your ability to acquire certain social skills.
^ Personalization: The patient is especially sensitive to relating the behavior of
others, without sufficient evidence, with their social behavior perceived as
inappropriate.
10 Consult the link “Diagnostic Criteria for AD” (DSM-IV-TR) in the Resource Guide.
Anxiety disorders
CAMPUS
UNIVERSITY
In turn, these cognitive distortions would interact with the "symptomatic" vicious circles of
the phobic type.
Anxiety disorders
CAMPUS
UNIVERSITY
COGNITIVE MODEL OF SOCIAL PHOBIA
LEARNING HISTORY AND BIOLOGICAL FACTORS (1)------------ COGNITIVE SCHEMES (2 )
• Threats or fear of being disapproved, criticized, or rejected for social incompetence or

for acting in a certain way.
CURRENT ACTIVATING SOCIAL SITUATIONS (3)------------- COGNITIVE DISTORTIONS (4)
• Catastrophic vision.
• Danger maximization.
• Minimization of security.
• Polarization.
RESULTING INTERACTIVE CIRCLE (VICIOUS CIRCLE) (5)

Thought (Making mistakes, Self-criticism, Rejection, Criticism)--Affect (Anxiety)--
Behavior (Avoidance, Non-assertiveness).
5 Get the patient exposed to avoided social situations, reducing or eliminating their
tendency to experience anxiety and avoidance behaviors in them.
^ Develop cognitive-behavioral skills in the patient that allow them to
Anxiety disorders
CAMPUS
UNIVERSITY
confront avoided social situations.

6 Make the patient less vulnerable to social situations,
modifying their tendency to process social situations in a
threatening way and their attitudes (schemas) towards
them.
Anxiety disorders
CAMPUS
UNIVERSITY
In this way, the objectives are referred to the main components of the phobic problem:
the situational-behavioral; cognitive or evaluative and social coping skills.
4. EVALUATION QUESTIONNAIRES . They are aimed at identifying and quantifying the

components of Social Phobia. Some questionnaires refer to the identification of phobic
situations and the degree or intensity of anxiety and avoidance experienced in them,
others are aimed at detecting dysfunctional cognitions involved in these situations and
finally others are intended to assess the degree and type of social ability of the individual.
patient in managing those situations. As a sample of questionnaires referring to these three
areas, we mention:
1) Social Phobia Scale (Liebowitz, 1987): Contains 24 items referring to situations that are
frequently avoided by social phobics. The patient evaluates them in two dimensions:
fear or anxiety that they generate (From 0=None to 3=Severe) and avoidance of them
(From 0=I never avoid it to 3=I always avoid it). Furthermore, the 24 items are divided
into two categories: performance anxiety (performing tasks in social situations, e.g.
working while being watched, telephoning in public) and social anxiety (social
relationships, pe talk to unfamiliar people or go to a meeting). This allows the evaluator
to obtain four sub-ratings: social anxiety, performance anxiety, performance avoidance
and social avoidance.
2) Social Skills Questionnaires (M. Segura, 1982): It includes 20 types of social situations
that are described as a story as if the patient were involved in it (eg "There is a party,
you enter with the intention of introducing yourself") and are given three response
alternatives, among which the patient chooses the one that best describes his or her
way of acting towards them. The evaluator categorizes the responses into three
sections: appropriate or assertive behavior, behavioral inhibition, and inappropriate
behavior (due to anxiety or inability). This categorization can serve as a guide for
intervention (eg assertive training in the case of inhibition, exposure in the case of
anxiety and social skills training in the case of disability).
Anxiety disorders
CAMPUS
UNIVERSITY
3) Thoughts in Social Situations Questionnaire (M. Segura, 1982): It consists of 45 items

referring to typical and dysfunctional thoughts in social situations (eg "I feel like they
are watching me", "They are going to reject me", etc.). The patient evaluates the
frequency of its appearance (from not at all to frequently).
4) Rathus Assertiveness Scale: It consists of 30 items that the patient rates from "very
characteristic of me" to "very opposite to my characteristics."It refers to behaviors
where the patient aims to express opinions, requests or denial in the face of certain
pressures from others (eg "I have hesitated to make appointments or accept
appointments because of my shyness", "When I don't like the food they serve me in a
restaurant I complain to the waiter").
5) Bowers Assertiveness Questionnaire: Along the same lines as the previous one, but
categorizing the answers into three sections: situations where the patient does not
behave assertively, people with whom he does not behave assertively, and desired
objectives in situations where he does not behave assertively. behaves assertively.
6) List of Erroneous Traditional Assumptions (Davis et al., 1982): It is a list of Beliefs that
violate the legitimate rights of the individual to behave assertively (personal self-
assertion). The therapist can present it to the patient so that he can evaluate his beliefs
in them. Also that list attaches its counterpart of Beliefs in them. This list also includes
its counterpart of assertive beliefs, which can be used as therapeutic objectives.
7) Use of role-playing: The therapist can ask the patient to perform a certain behavior in
person in a social situation represented in the consultation (eg "Refusing to buy from a
door-to-door salesperson") and thus evaluate different aspects of that behavior.
Likewise, you can use rating scales to code different aspects of these behaviors (eg
Social skills assessment scales from Wilkinson and Canter, 1982).
5. THE INTERVENTION PROCESS. As in other disorders, the process follows a sequence of the
following type:
Anxiety disorders
CAMPUS
UNIVERSITY
1) Evaluation and conceptualization of problems. Special attention to the situational,

cognitive and behavioral component: Avoided social situations, threatening and non-
coping cognitions and behaviors (assertive, inhibition, avoidance).
2) Therapeutic Socialization: Explanation of the thought-affect-behavior relationship,
therapy objectives and Self-Registration procedure.
3) Modification of the problematic interactions: Cognitive skills
and
behavioral measures to break or interfere with the vicious circle.
4) Modification of the Assumptions Personals who do vulnerable to
the
patient. Cognitive-behavioral alterations.
5) Termination: Prevention and monitoring.
1) 1. COGNITIVE TECHNIQUES:
1) Debate of Irrational Beliefs (Personal Assumptions): Using the principles of RET,
the therapist models how the patient can debate the dysfunctional beliefs that are
at the basis of their disorder (e.g. Irrational belief detected: "I need the approval of
people important to me to be happy" and Related secondary beliefs: "I can't stand
it when people disapprove of me", "It's horrible if people reject me" and "If people
reject me" reject, I'm not worth it").
• Questioning: What law obliges other people to give me the approval that I
expect from them? What am I exposing myself to if in order to function
personally I have to first have someone's approval? Where is the proof that
when they rejected me it was the end of the world? Where is it written that my
value depends on the opinion of others?...etc.
• Generate Rational Alternatives: "I would like to have the approval of the
people I care about but it is not absolutely necessary", "If they reject me it is
Anxiety disorders
CAMPUS
UNIVERSITY bad, but not the end of the world", "Value myself based on the opinion of
others or by a criterion It is absurd because it is impossible to find a total
criterion to measure
Anxiety disorders
CAMPUS
UNIVERSITY
"As a person, it is better to accept myself with my defects and virtues and try to
change my defects, if I can."
• Behavioral alternatives to develop rational beliefs: Taking risks and exposing

oneself to social situations and possible criticism, assertive training to affirm
one's opinions before others, etc.
2) Search for evidence and alternatives to Automatic Thoughts and Personal
Assumptions:
• Decatastrophication of anticipated consequences ( eg How serious would it be if

they rejected you? Could you do something if it were to happen? What are the
real chances of those consequences happening? How long would the effects of
those consequences last? Do you usually think that X is going to happen, and
how many times has it really happened?); Balance of advantages-disadvantages
(Thinking that, what good is it?), Generating credible alternative thoughts
(Could we see that situation from other points of view?), Request for evidence
(What evidence do you have to think that?, And what evidence against?) ..etc.
The therapist can then model these methods for the patient to perform.
Personal assumptions can be tested through personal experiments and other
methods (e.g. Could we test the validity of his personal rule: "To do something I
have to have people's approval").
3) Stress Inoculation11 .
2) 2. BEHAVIORAL TECHNIQUES: Its purpose is to provide corrective experiences to

dysfunctional cognitions, either by modifying attributions and evaluations and social
incompetence ("I don't know how to handle myself in social situations", "I get nervous and I
don't know what to say"…) or disconfirming catastrophic expectations and related
avoidance behavior ("I can't stand being looked at", "If I get nervous I have to leave", "If
they criticize me I won't be able to stand it"...).
11 See the section regarding Simple Phobia. Additionally, in the Resource Guide there is a Stress
Inoculation Manual.
Anxiety disorders
CAMPUS
UNIVERSITY
1) Training in Social Skills : Indicated especially in cases where the patient does not have
skills to face social situations and that reinforce cognitions of personal incompetence.
The therapist identifies related situations where the patient appears incompetent,
represents it with the patient, and models alternatives that the patient reproduces and
gives him feedback about it. This process can be enhanced if at each step the
cognitions associated with incompetent behavior and possible alternative cognitions to
trying out new skills are identified. Role-playing, modeling, behavioral rehearsal,
cognitive and self-instructional techniques, and homework are often part of cognitive-
behavioral social skills training.
2) Assertive Training: It is a type of social skill indicated in cases of social inhibition (the
patient knows how to do it but avoids it for fear of the consequences) and social
incompetence. Its ultimate purpose is for the patient to express their opinions, desires
and feelings (positive and negative) in a persistent, but respectful manner with others
(non-aggressive). At a cognitive level it is about "decentering" the patient's
dependence on external evaluation criteria and self-affirmation in personal ones. It
may be useful prior to assertive training to present the beliefs that maintain non-
assertive behavior and the beliefs that support personal rights, and review their
implications with the patient. This can prevent assertive behavior from being dissonant
with a personal value (e.g. that "you must always put other people's desires before
personal ones").
3) Gradual Exposure to Avoided Situations: For the patient to perceive that their social
behavior is effective (expectation of self-efficacy and disconfirm their threatening
cognition), it is usually necessary to expose themselves to previously avoided
situations. The therapist can agree on task assignments toward more or less gradual
approaches to these situations.
7. CLINICAL CASE (J. J. Ruiz Sánchez).

1) Identification data:
Anxiety disorders
CAMPUS
UNIVERSITY
• 19-year-old single man and 2nd Bachelor student.

• Referred by the general practitioner.
• "I want to definitively end the problems that I have always had: insecurity,
shyness, fear of having a normal relationship with people. It is very difficult
for me to meet a person and speak in class. Write down, I have more stable
and sincere friends. When I was little, my classmates hit me a lot. I have
been very pampered and overprotected by my family, especially by a great
aunt. "I have an inferiority complex when it comes to people, I don't value
myself at all, I think I'm worthless."
• He adds that at home he argues a lot with his father about any topic. They
have very opposite opinions on almost everything. He likes to argue about
who is right on a topic. In class he is afraid to speak in front of others. He
has a hard time talking to girls and making new friends. He says he is very
distrustful. He plays in the town's municipal band and the same thing
happens to his colleagues, "I don't like to stand out," he adds.
3) Symptoms:
• Cognitive:
- Being right on an issue ("Fallacy of Reason").
- He thinks they are watching him in class ("Personalization").
- "I won't know how to answer, I'll get very nervous" ("Catastrophic Vision").
- "I'm not very cool with girls, they're not going to like me "
("Overgeneralizing Labeling" and "Arbitrary Inference").
- “I'm not up to the task" ("Selective Abstraction").
- Ruminating self-criticism: "I could have done better."
• Affective:
- Irritable when arguing. Later guilt.
- Anxious about the presentation in class, girls and strangers.
• Motivational:
Anxiety disorders
CAMPUS
UNIVERSITY
- You would like to have easier social relationships.

• Behavioral:
- Difficulty expressing yourself socially.
- Avoidance of certain social situations (eg start a conversation with
a girl).
- Argue to be recognized.
• Physiological:
- Muscle tension. His voice trembles. His hands are sweating.
• His mother, who attends the first interview, reports that her son has always had
problems relating. At 6 years old, when he had to go to school, he would get
very nervous, cry and return what he had eaten. The parents insisted until he
managed to go. His mother continues to report that since he was little he was
very shy, they hit him a lot in class, they didn't leave him alone. When he
started studying 1st Bachelor's degree, his classmates laughed at him. He didn't
want to go to school, his mother talked to the teachers and this problem was
solved.
• He has received treatment from psychiatrists 3 times. At the age of 7 he was

treated for "night terrors", the second time at the age of 14 and the third time
at the age of 16, being diagnosed with "reactive neurosis". Later, he has
occasionally consulted psychiatrists. He currently takes "Tepazepam" one
tablet, when he is most nervous, helping him somewhat to calm down
(prescribed by his family doctor). The patient adds: "In the consultations with
the psychiatrists they gave me medication and told me to do my part and
reason things better. That didn't help me much, my parents and myself already
told me."
• Normal pregnancy, although the delivery was somewhat late. Normal physical-
Anxiety disorders
CAMPUS
UNIVERSITY psychomotor development. Schooled since the age of 6. His studies are going
well in terms of performance (grades). He was released from military service
due to problems in
Anxiety disorders
CAMPUS
UNIVERSITY
until recently she has worn a corset (almost a year and a half). He does not
have a partner and has not had sexual relations to date.
• He lives with his parents. The 47-year-old father works in a car factory. His 46-
year-old mother, a housewife. He has two brothers, one who is 18 years old,
male and who works in street vending, single. The other brother, 8 years old,
male, studies 3rd EP The maternal grandmother usually spends the day at
home and the night at home. A maternal uncle abstained from psychiatric
treatment for depression two years ago. He describes his family as "very
nervous."
6) Diagnosis:
• Social anxiety disorder.

• Avoidant (phobic) personality traits.
7.2 FUNCTIONAL-COGNITIVE ANALYSIS AND CONCEPTUALIZATION OF PROBLEMS. Two

problems were detected :
1) Anxiety and assertiveness problems in social situations.
2) Tendency to argue to impose your reason. Related to these behaviors , different
cognitive aspects were detected:
* Inappropriate evaluations of facts: "I have to avoid making mistakes"
(Should-Perfectionism). "My family always wants me to do what they tell
me" (Overgeneralization).
* Inappropriate Attributions: "My problems are due to my introversion and
shyness."
* Unrealistic Expectations: "If you ask me, I won't know how to answer and I
will get very nervous" (Catastrophic Vision, Overgeneralization).
* Inappropriate self-evaluations: "I am to blame for my problems", "I am not
very cool, people are not going to like me."
* Personal Assumptions (Hypothesis): "I have to do things very well, and not
make mistakes to have the recognition of others." These cognitive
Anxiety disorders
CAMPUS
UNIVERSITY components interacted with their social anxiety, non-assertiveness and
tendency to argue, anger, and guilt.
Anxiety disorders
CAMPUS
UNIVERSITY

> Session #1:
• Clinic history.
• Functional-Cognitive Analysis and conceptualization of problems.
> Session No. 2:
• Presentation of the ABC Model of Ellis' RET.
• We detect "Irrational Belief" of the type "I have to be very competent and
avoid making mistakes to be socially approved" (Insight No. 1 of the RET).
• Presentation of refutation methods. Record.
• Homework: Recording events (A) related to social fears and arguments.
Detection of emotional and behavioral consequences (C). Detection of
irrational beliefs (B). Rebuttal (D) and new emotional-behavioral
consequences (E) (Enhance Insight #2 and 3).
> Session No. 3:
1. He has made the refutation with some difficulties: pe
• Situation. In literature class talking about astrology with some
classmates.
❖ State. Nervous (7).

❖ Thoughts/Demands. Longing for recognition by others. Desire for
reward.
❖ Questioning.
• What evidence in favor?
V Not looking good, getting nervous, I don't like being
the center of attention .
• What evidence against it?
Anxiety disorders
CAMPUS
UNIVERSITY
V Everyone in the class speaks in public and nothing

happens to them.
• What is the worst if it is not fulfilled?

V I'm going to feel frustrated.
2. I explain that it remains at the level of the initial thoughts and that it is
convenient to continue asking about them (eg What is the worst if I get
frustrated? What forces others to recognize me? Seems to understand the
process (Feedback). Difference Cr.Rac/Irrac.
3. I explain Exposition Technique and Assertive Training. We do role-playing :
"How to respond to criticism " (Disco Rayado, Banco de Niebla).
4. Homework:
• Cognitive refutation (DE). Same focus (A).
• Exposition in the imagination: Scene where the boys make fun of

him in class. Do this until you achieve a self-exposure time of 20
minutes (goal).
• Assertiveness: On 4 occasions, look for a topic with a certain

disagreement with a friend and use a fog bank and a broken record
instead of arguing.
> Session No. 4:
1. He has performed the RET refutation more successfully, with greater
benefits on his interpersonal anxiety and anger. For example:
■ . Situation: At the pub, a girl asked me to sit with her.
■ Status (0-10). Unsafe (6). Anxiety (6).

■ Thoughts/Demands. I must like him.
■ Questioning. I don't need to like you to continue the day
with other satisfactions. Nothing requires me to have to be
liked by everyone.
■ Result. Nervous and insecure (3).
■ . Situation: Argument with my mother and father in the living
Anxiety disorders
CAMPUS
UNIVERSITY room. Late.
Anxiety disorders
CAMPUS
UNIVERSITY
■ Status (0-10) . Anger (8).

■ Thoughts/Demands. Recognition. You have to agree with
me.
■ Questioning. I don't really need to be proven right. I can find
other satisfactions.
■ Result. Anger (3).
2. He has successfully applied the assertive task, although with a friend it has
not been so difficult. The exhibition has been carried out 4 times without
any problem. I reinforce your collaboration.
3. I present a list of personal rights. He identifies which rights he usually
defends and does not defend in other cases. Analogies are also presented
of what rights I would have if I were "Accused of a crime" (answer-having a
lawyer, being able to provide evidence, being heard...), "Being a child"
(answer-not being told things abruptly, being able to defend myself),
"Being a boyfriend" (response-consideration of my point of view) and
"Employment interview" (response-being evaluated well). You agree to the
identified rights.
4. Homework:
■ Follow RET refutation

■ Assertiveness: Saying something positive to a girl (looks, clothes,
etc.).
■ Bibliotherapy. M.Smith- "When I say no, I feel guilty."
^ Session 5 to 7: Idem to the previous ones with gradually more difficult assertive
tasks (eg invite a little-known classmate to coffee, etc.).
■ She also begins parallel group therapy with two girls in our service. This
group is aimed at assertiveness. Role-playing, modeling, behavioral
rehearsal, RET are used. and homework. These two girls also present
assertiveness problems (one case of Depressive and Assertiveness problem,
and one case of Anxiety Disorder-Dependent Personality Traits).
Anxiety disorders
CAMPUS
UNIVERSITY
5 Session No. 8 to 15 : We also work with the CT method (Beck) to focus on the related
problem ("Insecurity. Fear of the future. The previous line is developed.
^ Results:
1. Disappearance of fears of speaking in class.
2. Disappearance of fears about relationships with girls.
3. Reduction of arguments with your family.
4. Cognitive Modification:
- Difference desire for approval from demand for approval.

- Accept the impossibility of absolute security regarding the future.
"When problems come I will face them, I am not going to anticipate
events."

- SOCIAL ANXIETY DISORDER -
Among the Psychological Treatments for this disorder, it is worth mentioning:
• Cognitive-Behavioral Treatments.
• Exposure.
• Relaxation.
• Training in Social Skills.
Regarding Cognitive Therapy, it is very important, since thoughts are the basis of most
actions carried out by the patient. The explanation will be made in a summary way, since it
was explained in greater detail in the section on the Treatment of Panic-Agoraphobia.
The procedure to follow in Cognitive Therapy is the following:
^ First of all, the patient must learn to identify what negative thoughts they have. Self-
registrations are used for this, training you for it.
> Once registered, we proceed to discuss those automatic thoughts,
Anxiety disorders
CAMPUS
UNIVERSITY
and then provide alternatives to those proposed thoughts. In it

discussion process it is advisable to record negative thoughts, as well
like the given arguments, since when they are written they are better observed.
5 Another of the fundamental questions to ask is to expose
yourself to the feared situation. To do this, a list of
situations must be made and ordered according to the
degree of discomfort they produce. Once done, choose the
first situation of the hierarchy and the patient has to design in detail how he is going
to act in that situation: what he is going to do and what behavior he will have to
perform. In addition, you will also have to try to predict what is going to happen,
generating an alternative for each proposed event.
^ Regarding Relaxation, we refer the reader to the section on Treatment for Panic-
Agoraphobia, since this technique is explained in more detail.
^ One of the most important techniques in the Treatment of Social Phobia is Social
Skills Training, within which the following 9 aspects will be worked on:
• Assertiveness.
• Expression and Reception of Criticism.
• Make requests.
• Say no".
• Express and Receive Positive Feelings.
• Start, Maintain and Close Conversations.
Anxiety disorders
CAMPUS
UNIVERSITY
9
We will deal with them one by one.
To begin Training, first of all, it is necessary to explain to the patient the differentiation between verbal and non-
verbal behavior.
* These aspects were already developed extensively in the Social Skills Training Module.
Anxiety disorders
CAMPUS
UNIVERSITY
GENERALIZED ANXIETY DISORDER
1. DIAGNOSTIC GUIDELINES FOR GENERALIZED ANXIETY BY THE DSM-V12 .

2. THE COGNITIVE MODEL OF GENERALIZED ANXIETY: THE BECK MODEL (1985).
It is based on the idea that the patient throughout his

development has acquired a series of cognitive schemes
referring to threats that are activated in certain situations.
This activation would trigger cognitive distortions and
automatic thoughts.
referring to expectations, threatening images, perceived inability to cope (at a cognitive
level), which would in turn produce emotional activation-arousal (at a behavioral level).
Beck states that the individual's perception is incorrect, being based on false premises.
These perceptions refer to threatening content about dangers to the patient's interests
and their inability to confront them. The underlying cognitive schemes are usually
ideosyncratic, although thematic content referring to threats to social relationships,
personal identity, execution-performance, autonomy and health are common.
The cognitive distortions that appear in Generalized Anxiety Disorder are:
^ Arbitrary Inference-Catastrophic Vision: It consists of the anticipation or
12 Consult the link “Diagnostic Criteria for AD” (DSM-V) in the Resource Guide.
Anxiety disorders
CAMPUS
UNIVERSITY
catastrophic assessment, not based on sufficient evidence, about certain

anticipated dangers that are perceived as very threatening by the patient.
^ Maximization: The patient increases the probability of the risk of harm.
Anxiety disorders
CAMPUS
UNIVERSITY
5 Minimization: The patient perceives his ability to cope with physical and social
threats as greatly diminished.
In Anxiety, Panic and Phobia Disorders, the cognitive activation of threat schemes would
produce a type of "cognitive bypass": a type of avoidance, short circuit or difficulty for the
patient's rational thinking to operate; The primitive information processing system would
compete with the rational and evolved processing system. This would explain the typical
"neurotic conflict" between reason and "irrationality" perceived by the patient in his
cognitions. In the following figure we represent the model.
Personal History and Biogenetic Factors (1)----------"Training context"--- Outlines

Cognitive (2)
• Dangers-threats referred to: Social Relationships, Personal Identity, Performance,

Autonomy and Health.
CURRENT TRIGGER EVENTS---------------------------------------- COGNITIVE DISTORTIONS (3)

• Danger maximization.
• Minimizing safety and coping skills.
• Anticipation of damage (catastrophic vision).
RESULTING INTERACTIVE CIRCLE

Thoughts-------------------------Affects/Physiological Activation------------------Behaviors
Apprehension Anxiety Inhibition of speech and
movement
Indecision Muscle tension Escape or avoidance behaviors
Anxiety disorders
CAMPUS
UNIVERSITY
Thoughts about threats Neurovegetative Symptoms
1) Reduction in the frequency, intensity and duration of
autonomic activation/anxiety.
Anxiety disorders
CAMPUS
UNIVERSITY
2) Reduction of avoidance, flight or inhibition behavior.

3) Facilitation of the acquisition of coping skills and generalized anxiety.
4) Identification and modification of the cognitive basis of the disorder: Cognitive
Distortions and Cognitive Schemes (Personal Assumptions) that make the patient
vulnerable to suffering from anxiety.
4. EVALUATION QUESTIONNAIRES . There are many questionnaires aimed at evaluating

anxiety. We are going to refer some of them following V's guidelines. Conde López and JL
Franch Valverde. The aforementioned questionnaires are used to quantify the
symptomatology of Anxiety Disorders. For the evaluation of cognitive distortions and
personal beliefs, questionnaires similar to those for the evaluation of other disorders (
Treatment of Depression) are used 11 .
1) Hamilton's Hetero-Applied Scale for the Evaluation of Anxiety (1959): It is
composed of 14 items, each corresponding to a set of anxiety manifestations. The
evaluator assigns a score from 0 to 4 depending on the frequency and intensity in
which the symptoms occur.
2) Hamilton's Self-Applied Scale for the Evaluation of Anxiety (Conde and French,
1984): Identical to the previous one, but allowing the patient to self-evaluate the
symptoms.
3) Zung Anxiety Scale (Zung, 1971): Composed of 20 items with the possibility of
scoring from 1 to 4. There is a hetero-applied version and another self-applied
version.
4) Taylor Manifest Anxiety Scale (Taylor, 1953): It consists of 50 items that the
patient evaluates as "true" or "false." It measures trait anxiety, not state anxiety.
Although it is not designed to measure symptomatological changes, its global score
is related to symptomatic changes.
5) Anxiety-Depression and Vulnerability Scale (Hassanyeh et al, 1981): It is
11
They will be seen extensively in the Mood Disorders Module.
Anxiety disorders
[157]
CAMPUS
composed of 63 items to which the patient must answer "yes" or "no". These items
UNIVERSITY
score on three scales: Anxiety Subscale, Depression Subscale, and
11
They will be seen extensively in the Mood Disorders Module.
Anxiety disorders
[158]
CAMPUS
UNIVERSITY
Subscale of Vulnerability to suffer an Emotional Disorder. The Depression subscale

and Vulnerability to suffer an Emotional Disorder subscale. The Depression
Subscale correlates with the BDI (O.90) and the vulnerability subscale with the N
scale of Eysenck's EPQ. This scale allows the evaluator several dimensions that can
be presented together in the clinic.
6) Beck-Pichot Self-Applied Scale for the Evaluation of Depression-Anxiety: It consists
of a scale that adds 10 items to the original 21 of the Beck scale. These 10 items
collect information about anxiety symptoms. It is a self-applied scale. It can be
useful to evaluate anxiety-depressive symptoms.
5. THE INTERVENTION PROCESS. The intervention process follows a similar line to the CT of
Depression Treatment:
1) Patient socialization in the Cognitive Model of Therapy: Thought-affect-behavior
relationship, role of automatic thoughts and therapy as learning cognitive and
behavioral alternatives for the management of personal vulnerability.
2) Elicitation of Automatic Thoughts: Use of Self-Records. The therapist takes note of
the associated meanings so that he or she can hypothesize personal assumptions.
3) Assessing the Validity of Automatic Thoughts: evidence, alternatives,
consequences, personal experiments for threatening and non-coping predictions
(e.g. using behavioral skills).
4) Identification of Personal Assumptions and Examination of their Validity (idem to
previous section).
6. COGNITIVE TECHNIQUES. Its central function is based on the identification of the patient's
threatening and non-safety perceptions; and once identified (along with the associated
meanings) by offering a framework for their evidential contrast ("reality tests").
Anxiety disorders
CAMPUS
UNIVERSITY
1) Questioning Catastrophic Thoughts: The therapist teaches the patient to question

his or her catastrophic thoughts: "How likely is it to happen? Could something be
done if it were to happen? How long would the effects last? Would it be so serious?
Others times thought about it, and what really happened?"
2) Use of imagination: The patient can imagine threatening situations and their
coping with them along with self-control instructions. Threatening situations can
also be prioritized (eg in the form of systematic desensitization).
3) Other Cognitive Techniques ( Ellis's Rational Emotive Therapy and Beck's
Cognitive Therapyhttp://www.redsanar.org/drfobia/Terapias/manual2b.htm )
6.1. BEHAVIORAL TECHNIQUES : Their function is to provide evidence to the patient that
modifies their threatening expectations and their perception of inability to cope (that is,
they increase self-efficacy expectations).
1) Relaxation Techniques: Induces cognitive distraction and ability to reduce anxiety
activation.
2) Assertive Training: Aimed at increasing the patient's ability to self-assert and
reducing behavioral inhibitions.
3) Exposure Techniques: When it is possible to identify respective and frequent
situations related to anxiety, the patient can learn to face them without avoiding it
(lively and/or in imagination) so that they become accustomed to them and
disconfirm their expectations.
7. CLINICAL CASE (Therapist: S. Alario Bataller. Adaptation: J. Ruiz).

1) Personal identification data:
• 35-year-old man, single and professor.

• He requested the consultation on the advice of a friend who had been treated
by this therapist.
Anxiety disorders
CAMPUS
UNIVERSITY
2) Reasons for consultation: You are constantly anxious. He has periods of depression
and severe headaches.
3) Symptoms:
• Cognitive : Worry, fear and fear that something calamitous will happen to him
or her
his mother.
• Affective:
- Constant anxiety.
- Periods of sporadic sadness.
- Occasional irritability.
• Physiological:
- Motor tension (tremor, muscle pain, fatigue, restlessness, restlessness...).
- Vegetative hyperactivity (sweating, palpitations, tachycardia, hands
sweaty, gastralgia...).
- Conciliation insomnia.
- Weight gain (8 kg. in 15 months).
• Motivational: Impatience.
• Behavioral : Maintains few social relationships.
4) History of the problem and previous treatments: He has received several
treatments: one with a psychologist (psychodynamically oriented), another three,
with three psychiatrists (also psychodynamically oriented), in addition to the last
one with a neuropsychiatrist; The patient complains about the high cost of these
therapies, which for him have not helped him overcome his problems.
• Since I was little I was afraid of being injured, hurt, attacked, of death; in
general to everything that involved something tragic or violent. He relates the
beginning of these fears to the death of a girl in his neighborhood. He also
adds, at the age of 7, he was very scared when he witnessed a fight between
two adults. Since then he remembers that he is disturbed by shouting and
Anxiety disorders
CAMPUS
UNIVERSITY fighting.
Anxiety disorders
CAMPUS
UNIVERSITY
• His father was a big-mouthed, strong, very energetic and dominant man. He
screamed for nothing and, in his presence, the patient looked distressed. His
mother was like a shadow; submissive, never said anything. His father
constantly criticized the patient's shy and withdrawn appearance, and he did
not like anything he did . "He never laid a hand on me, but he was the cruelest
person in the world to me." "He didn't like how I ran, how I played soccer, and
later he disliked the books I read and even the career I chose." His father died in
a traffic accident when the patient was in his second year of college, which was
a "great liberation" for him. He remembers much of his life as a tragedy, finding
himself continually anxious, irritable and depressed.
• Academically he was always brilliant, although socially inhibited. A teacher

who, for the patient, resembled his father in character, accused him of anxiety,
especially when he received criticism from him.
• The patient's sexual life had always been scarce, without showing much
interest in this topic.
• Currently the patient lives with his mother and his social relationships are
academic.
6) Diagnosis: Generalized Anxiety Disorder.
7.2. FUNCTIONAL-COGNITIVE ANALYSIS AND CONCEPTUALIZATION OF PROBLEMS. The

Functional-Cognitive Analysis detected that the patient's anxiety was related to three types
of situations:
• Criticism and rejection (personal devaluation).

• Fights and physical aggression.
• Self-affirmation or personal assertiveness (manifestations of opinions and personal
desires before others). Jointly and related to these situations, automatic thoughts
were detected related to the anticipation of misfortunes and catastrophes that
could occur (Catastrophic Vision: "I'm going to die one of these days", "I'm going to
explode") and with the minimization of the control of these
Anxiety disorders
CAMPUS
UNIVERSITY
situations ("this is horrible, I will never get rid of it", "I can't stand this horrible knot
in my stomach"...).The hypothesis about the supposed personal at the base could
be... "I can't stand it when people criticize me or are aggressive towards me."

^ Session #1 to #8:
• Dedramatization of the situation: Relaxation Training and Systematic

Desensitization to the hierarchies developed from the 3 typical situations
of Functional Analysis.
• Evaluation of the degree of suggestibility (positive), training in self-hypnosis

for the management of insomnia.
• Programming of mastery-pleasant tasks to increase the patient's repertoire

of activities (referred to work-home with the mother).
> Session #12 to #30:
• Use of distracting techniques: changing negative thoughts/stopping

thoughts and using visualization of pleasant scenes.
• Verification of catastrophic predictions: use of cognitive techniques

(especially hypothesis testing or personal experiments). For example, the
patient anticipated that if he received criticism from a colleague,
misfortunes could occur ("I'm going to explode", "I won't stand it", etc.); He
"exposed" himself to those potential situations and verified the lack of
evidence for his predictions.
> Session #30 to #45:
• The verification of predictions continues.

• Assertive training is worked with the patient as a way of
maximize their social coping skills and as a way to modify their cognitions
of personal disability. Role-playing, modeling, behavioral rehearsal is used
(eg how to respond assertively to criticism) and implementation tasks;
together with cognitive methods.
Anxiety disorders
CAMPUS
UNIVERSITY
5 Results: A follow-up was carried out at 6 months and one year. This person reported
that he had not experienced anxiety problems and that his social and professional
relationships with his colleagues had greatly improved.

- GENERALIZED ANXIETY DISORDERS -
The treatment plan of Brown, O'Leary and Barlow (taken from A. Bados).
> Relaxation Training.
It is based on Bernstein and Borkovec's Progressive Relaxation Training . It is explained
to the patient that the purpose of Relaxation is to reduce the physiological symptoms of
anxiety and, in this way, contribute to the reduction of worries. It starts with 16 muscle groups
with discrimination training. This consists of teaching to discriminate the sensations of tension
and relaxation in each muscle group; The goal is for the patient to become better able to
detect the sources and early signs of muscle tension in order to apply Relaxation Techniques.
After finishing the 16 groups, relaxation deepening techniques are used such as slow, regular
and diaphragmatic breathing with the repetition of the word relax when exhaling. This entire
process usually lasts about 30 minutes and the therapist usually records the procedure on
tape so that the patient can practice with it twice a day. The sequence of muscles that is
followed is arms, legs, abdomen, chest, shoulders, neck, face, eyes and forehead.
After mastering the 16 muscle groups (it usually takes about 2 weeks) the number of
muscle groups is reduced to 8 and then to 4 (e.g., abdomen, chest, shoulders, forehead) so
that Relaxation can be applied more quickly. The specific muscles considered are determined
by the areas of the body with which the patient has the most problems. The next step is
Relaxation through memory: concentrate on the 4 selected muscle groups and release the
tension existing in them by remembering the Relaxation sensations achieved in the previous
practices. The practice of slow breathing and practices in a quiet environment is continued,
but the
Anxiety disorders
CAMPUS
UNIVERSITY
patient to begin practicing briefly in other environments that do not raise anxiety (car, office,
certain lines, watching TV).
Once you have mastered Relaxation through memory, you move on to Relaxation
provoked by the signal: take 4–5 slow breaths, repeat the word relax or another similar word
to yourself as you exhale and, by doing this, release all the tension in the body and
concentrate on the sensations of relaxation. The patient is asked to practice this type of
Relaxation in situations that induce tension or anxiety.
In addition, you are told to periodically continue exercising 16 muscle groups in order to
enhance discrimination training and the association of the relax signal with the sensations of
Relaxation.
Relaxation training can induce anxiety due to a special susceptibility to certain somatic
reactions and/or fear of losing control. This relaxation - induced anxiety is more frequent in
Semee'ad )
EMER- -a
patients who have comorbid Panic Disorder and
is negatively associated with treatment outcomes. When the therapist notices the occurrence
of said anxiety, he must inform the patient that it is a temporary reaction and that it will
subside with repeated practice of Relaxation.
Borkovec, Hazlett-Stevens and Díaz advise encouraging patients to let the worries they
detect pass during Relaxation instead of actively trying to suppress them, since the latter
increases their anxiety-producing value and perhaps their frequency. To further assist this
process, patients are asked to practice a stimulus control strategy: postponing worries to a
specific time and place of the day so that worrying does not become associated with the
circumstances of daily life. Additionally, patients are encouraged to practice directing their
attention to present-moment experiences rather than thoughts about the past or future
present in their worries as soon as they postpone a worry or apply a Relaxation response.
5 Cognitive Restructuring.
Anxiety disorders
CAMPUS
UNIVERSITY
Follow Beck's principles. The concept of negative thoughts is

explained, the influence of situations on them, the impact of
interpretations and predictions on what we feel and do, and the need
to identify specific interpretations and predictions in order to
question them. The latter is achieved through questions, imagination
or simulation of situations and, especially, a Self-Record in which the
patient notes the following aspects every time they experience a
notable increase in anxiety: triggering event, automatic thoughts and anxiety (0-8). It is
important that the cognitions identified are specific (“my child could be in a car accident and
be paralyzed or die” versus “something bad could happen to my child when he goes outside”).
A common problem for both patients and therapists is not being able to identify those
thoughts that are mainly responsible for negative emotions; instead, attention is focused on
less important cognitions. Two ways to approach the problem are to use the downward
arrow technique and have therapists and patients ask themselves whether the identified
thoughts would produce the same type and degree of emotion in other people making the
same interpretation. Other frequent problems in Cognitive Restructuring, both by patients
and therapists, are questioning thoughts before identifying the most significant ones and
insufficient questioning of automatic thoughts (generation of incomplete or inadequate
counterarguments).
Basically two types of cognitive errors are considered : a) Overestimation of the
probability of occurrence of a negative event ; For example, a patient who, with a good
employment record and without good reason, believes that he is going to be fired from his job
. b) Catastrophic thinking or tendency to expect or interpret the worst (e.g., expecting terrible
consequences even from unimportant events) and to see something as intolerable and
unmanageable or impossible to deal with when there are no sufficient reasons to do so; For
example, thinking that one would be so devastated if one's spouse died that one would not be
able to bear it and rebuild one's life.
Anxiety disorders
CAMPUS
UNIVERSITY
After explaining and providing examples of the two types of errors above, it is
Anxiety disorders
CAMPUS
UNIVERSITY
It is advisable for the therapist to give some reasons why these thoughts persist even though
what was predicted does not come true: the belief that one has been lucky so far, the belief
that worrying and worrying behaviors prevent negative consequences. and the tendency to
focus on negative outcomes without considering other alternatives.
The next step is to emphasize the importance of challenging negative thoughts. It
involves examining the validity of the interpretations and predictions made in order to
replace them with more realistic cognitions. This questioning involves: a) considering
thoughts as hypotheses, b) using present and past data to evaluate the validity of what is
believed (Socratic Method ) and c) generating predictions from the belief to test it
(Behavioral Experiments). ). In the case of questioning the overestimation of the probability
of a negative event, these three types of guides are used to establish the realistic probability
of the future occurrence of the negative event.
Once the patient has grasped the basics of questioning his cognitions, four columns are
added to his usual Self-Record: anxious probability (0 100%, perceived probability of the
negative event when one is anxious), cognitive questioning (tests for what I think,
alternatives), realistic probability and anxiety (0-8) at the end of the process. If this anxiety is
4 or more, the patient is asked to reconsider the worst possible consequence involved in his
or her automatic thoughts and to repeat the entire procedure until the anxiety is 3 or less.
To challenge catastrophic thoughts, the patient is asked to assume that the worst thing
he fears is true and then evaluate whether it really is as bad as it seems. This involves
recognizing that you have means to handle negative events (including what these means are)
and that the impact of negative events will not last forever, but will be of limited duration.
Instead of continually focusing on the negative consequences of certain events (e.g., heart
attack), the patient must learn to generate solutions to them in the unlikely event that they
occur. Furthermore, it is very useful for the patient to generate as many alternative
interpretations as possible for the worst feared consequence; For example, alternative
explanations for the fact that you are going to have a heart attack because your heart is
racing are that you are very nervous about something, that you have had coffee or
Anxiety disorders
CAMPUS
UNIVERSITY
that you have exercised.

It is worth noting that decatastrophication is not about seeing a negative event as
unimportant or neutral (e.g., it would be very upsetting for most people to lose a child), but
rather critically evaluating its real impact. To work on decatastrophication, the patient is
asked to complete a Self-Registration in which they note: worry, ability to cope (0-100%) with
a negative event when anxious, means of coping, and realistic ability to cope once the means
are considered. previous.
5 Exposure to worry. Exposure to concern includes the following

Steps :
• Identify a patient's top two or three areas of concern and
Sort them starting with the least disturbing or anxiety-inducing.
• Train the patient's imagination by using pleasant scenes.
• Vividly evoke the first area of concern by asking the patient

to focus on his or her anxious thoughts while trying to
imagine the worst feared consequence that occurs to him or
her from that area of concern. Thus, a patient who worries
when his or her spouse arrives late from work may imagine
him or her unconscious and slumped over the steering
wheel of the car. And a patient who worries because a
friend stops by unannounced and sees the house dirty and messy can imagine that
she will call the rest of her friends to tell them and they will all laugh at her and lose
respect for her.
• Once the patient is able to vividly imagine the above, they are asked to recall the
thoughts and images again and keep them clearly in their head for at least 25-30
minutes. It is advisable to obtain periodic ratings of the patient's anxiety (e.g., every
5 minutes) to check whether it is reducing and, if not, to detect possible problems.
• After the previous time has passed, the patient is asked to generate as many
Anxiety disorders
CAMPUS
UNIVERSITY
alternatives
Anxiety disorders
CAMPUS
UNIVERSITY
as you can to the worst anticipated consequence. For example, in the case of a
spouse who is late, one can think of the following alternative explanations:
unforeseen event at work, taking time to talk to someone, traffic jam, broken down
car, minor collision with the car, or stopping to buy something. And in the case of a
friend's unexpected visit, you might think that she might not notice the mess; that he
will not give it importance; that he has come to see someone, not the house; that
even if she notices the dirty floors, she may not consider it important enough to call
the rest of her friends; You can be glad you don't always see someone cleaning. This
generation of alternatives can be done only verbally or also in the imagination.
• At the end of the generation of alternatives, the patient completes a Self-Registration

with the following data: start and end time, symptoms during exposure, content of
the worry, worst possible feared consequence, anxiety experienced (0-8), level of
imagination ( 0-8), possible alternatives and level of anxiety and imagination after
generating these
• When the exposure does not generate more than a mild level of anxiety (2 or less on
the 0-8 scale) despite several attempts to vividly imagine the worry, move on to the
next area of concern in the hierarchy. Once the patient is able to perform the
procedure well in the session, what is practiced in the session is assigned as an
activity between sessions.
It is very important to provide patients with adequate justification for the procedure.
This involves discussing the concept of habituation and explaining why it has not occurred
naturally despite repeated worries (due to the tendency to change from one worry to the
next without elaborating them sufficiently, due to the occurrence of defensive worry
behaviors) . Additionally, repeated exposure to the same worrying thought and/or image can
help the patient develop a more objective perspective on the worry. Finally, exposure to
worry provides the opportunity to apply strategies previously learned in the treatment
program (Cognitive Restructuring and, perhaps, Applied Relaxation).
Anxiety disorders
CAMPUS
UNIVERSITY
There are several problems that may arise in the application of exposure to concern .
1) Minimal anxiety during initial exposures . This may be due to: a) insufficiently
vivid images, b) overly general images that do not focus on the worst
consequence, c) images that are not important for the area of concern
considered, d) area of concern that does not appreciably contribute to the TAG,
e) application of coping strategies (Cognitive Restructuring, Relaxation) during
the 25-30 minutes of exposure, f) covert avoidance of the most important signs
of concern. This can be achieved through cognitive distraction, focusing on
pleasant or neutral cognitions or unimportant negative cognitions, or letting
thoughts fluctuate.
2) It is important for the therapist to be attentive to detect the presence of
distraction and to emphasize to the patient that although distraction from
anxious thoughts can reduce anxiety in the short term, it contributes to
maintaining it in the long term. Distraction reinforces the idea that certain
cognitions should be avoided, prevents the increase in anxiety necessary to
achieve emotional processing of worry, and therefore serves to maintain threat
interpretations. Finally, distraction does not allow anxiety-inducing cognitions to
be restructured. Little intra- or intersession habituation of anxiety to worry
signals despite repeated exposure to them. Possible reasons are : a) covert
avoidance when experiencing a lot of anxiety; b) failure to maintain the same
image throughout the exposure (changing from one disturbing image to
another), which reduces habituation to said image; c) insufficient exposure time,
either because it does not reach 25-30 minutes or because this last duration is
not sufficient for certain people or images.
3) Difficulty generating alternatives in general or credible alternatives in particular
to the worst anticipated consequence . This may reflect a capacity
Anxiety disorders
CAMPUS
UNIVERSITY
limited ability to apply previously learned Cognitive Restructuring or a strong

conviction that what is feared will happen. In this case, anxiety will not be
reduced. The solution is to ask the patient for his or her hypotheses about why
anxiety does not decrease, analyze and test these hypotheses, help the patient
generate alternatives to the worst feared consequence, and continue with
prolonged exposure to worry to help that greater objectivity is generated in
relation to the area of concern considered.
The type of exposure used by Barlow differs from that used in the treatments
investigated so far. In these, the patient is asked to imagine, in a hierarchical way, situations
and internal stimuli (cognitions, sensations) that provoke anxiety and after experiencing this
for a few moments, learn to manage it using the learned strategies (Relaxation and/or
Restructuring). The patient is not told, at least initially, to try to imagine the worst feared
consequence, nor does he have to spend 25-30 minutes imagining before applying his
strategies.
Dugas and Ladouceur have commented that worry exposure should only be done for
worries relating to unchangeable or very unlikely events; For the rest they advise some type
of problem solving. Furthermore, they think that other strategies should not be used during
exposure to worries about unchangeable or very improbable situations (even if only at the
end) such as Cognitive Restructuring (generating the greatest number of possible alternatives
to the worst feared consequence) and Relaxation. , since the use of these strategies could
reduce the effects of exposure by neutralizing the image of fear.
F Prevention of worrying behaviors.

Brown, O'Leary and Barlow understand worry behaviors as doing
(active avoidance) or not doing (passive avoidance) certain activities in
order to reduce or prevent anxiety and supposed anticipated dangers.
Anxiety disorders
CAMPUS
UNIVERSITY
Examples: frequently calling loved ones to check that they are okay, calling hospitals when a
child who
Anxiety disorders
CAMPUS
UNIVERSITY
traveling by motorcycle is delayed, arrive early for appointments, consult the doctor
frequently for symptoms of one's own or those of family members whose importance is
magnified, ask friends to reassure you about these symptoms, clean the house daily in case
someone unexpectedly comes to visit , overly ensuring that a job is well done, refusing to read
obituaries or unpleasant news in the newspaper, avoiding uncomfortable conversations,
postponing activities, not accepting invitations to social gatherings, not wanting to watch
certain TV programs, not going to the doctor, etc
These worry behaviors contribute to maintaining worries and threat interpretations and
must be prevented; Or more accurately, active avoidance behaviors should be prevented and
activities that the patient avoids should be encouraged. Both prevention and exposure can be
pursued gradually. Furthermore, prevention does not have to be total in cases where a
certain degree of the behavior is acceptable; Thus, a patient will not call the parents of
several of his daughter's friends if she has not arrived home at the scheduled time, but will if
60 minutes have already passed.
The way this procedure is usually approached with the patient is to view it as an
opportunity to test the patient's beliefs that worrying behaviors actually serve to prevent dire
consequences; That is, the hypothesis testing technique or behavioral experiment is used.
The first step is to make a list of common worrying behaviors with the patient and rank them
according to the degree of anxiety that preventing them would produce. An example of a
hierarchy is the following (the level of anxiety appears in parentheses): a) go see how the son
plays a rugby game (7, fear that he will get injured), b) do not clean for a few days (6- 7,
friends might notice and think badly), c) the husband does not call home all day (6, something
could have happened to him), d) not cleaning the bathroom in one day (5), e) not doing the
bed one morning (4), f) clean the bathroom only once in a day (3), g) the husband calls home
only when leaving work (2).
Examples of other possible hierarchy items for other patients could be listening to the
news on the radio instead of turning it off or changing the channel to avoid hearing reports of
traffic accidents; calling your spouse at work only once instead of several times; to be late
Anxiety disorders
CAMPUS
UNIVERSITY
to a date; read obituaries in newspapers; make some mistakes at work; Don't get up
immediately when the baby cries, do a weekly accounting review instead of daily. Once the
hierarchy has been developed, the patient is asked to record the frequency with which the
worrying behaviors occur throughout the week.
Next, you start at the lowest level of the hierarchy and ask the patient not to perform
the worrying behavior (or to perform the avoided behavior). Before carrying out response
prevention, the therapist and patient write down the latter's predictions regarding the
consequences that said prevention will have. Once this is accomplished, the patient is helped
to compare the results obtained with previous predictions in order to verify that worrying
behaviors are not correlated with a lower occurrence of future negative events. Once an item
of the hierarchy has been passed (2 or less on the 0-8 scale ) through the necessary number
of practices, we proceed with the next one. Before, during and after each practice the patient
can manage anxiety through Relaxation and/or Cognitive Restructuring.
Many patients with GAD feel overwhelmed by

5 Time organization.
obligations and deadlines in addition to everyday
problems that they tend to magnify. One way to
get these patients to focus on the tasks at hand
rather than on their worries about whether they
will be able to handle them or not is to teach them
time management and goal setting skills. Three
time organization strategies are proposed:
a) Delegate responsibilities , which means overcoming perfectionist tendencies.
b) Knowing how to say no and reject unexpected or excessive demands from others
that prevent the completion of planned activities . In both this strategy and the
previous one, hypothesis testing is used; For example, the patient delegates
Anxiety disorders
CAMPUS
UNIVERSITY
small tasks to co-workers or family members to test his predictions (“the work
will be of poorer quality,”
Anxiety disorders
CAMPUS
UNIVERSITY
“It takes me more time to explain it than to do it”, “they will think I am shirking
my responsibilities”).
c) Stick to planned plans . This involves structuring daily activities so that the most
important ones can be carried out. This is facilitated by setting daily goals.
When setting goals, each day's activities are classified into three categories:
• Activities A : Priority, must be done the same day.
• Activities B: Very important, they should be done soon, but not necessarily on
that day.
• Activities C : Important, they must be done, but not too soon. The patient is then
helped to allocate sufficient time to each activity; This time can be up to double
what the patient considers necessary in those people who do things hastily or
have unrealistic expectations of the time it will take to do things. The next step is
to schedule the times of the different activities; If the patient finds this too
restrictive or unfeasible on certain days, he or she can simply make a list of
activities A, B, and C for the day in three columns and cross them off as he or she
completes them.
Possible problems with time organization are difficulties in doing everything planned
for the day or in meeting deadlines. In these cases, the possible existence of excessively high
and unrealistic standards for one's own performance, and the perceived consequences of not
being able to do everything, should be investigated. The best interventions seem to be
Cognitive Restructuring and teaching the patient to stick to a daily schedule and allocate
plenty of time for tasks. Another possible problem is difficulty making decisions due to fear of
not making the right decision. Here, the fear of making mistakes and the perceived
consequences of these can be addressed through Cognitive Restructuring and hypothesis
testing.
Anxiety disorders
CAMPUS
UNIVERSITY
^ Problem Solving.
The Problem Solving Technique facilitates the identification of solutions to
existing problems and encourages patients to think differently about
situations in your life (instead of worrying exclusively), so that
adoption of more realistic and less catastrophic perspectives. It is explained to the patient
that two common difficulties when trying to solve a problem are : a) seeing the problem in
general, vague and catastrophic terms and b) not generating possible solutions. To address
the first difficulty, the patient is taught to define problems in specific terms and break them
down into smaller, more manageable parts; this will have already been done in part through
Cognitive Restructuring. Facing the second difficulty, the technique of brainstorming and the
evaluation of the different solutions generated is taught in order to select and implement the
solution or combination of solutions considered most appropriate.
Dugas and Ladouceur have pointed out that many patients with GAD do not lack
knowledge about how to solve problems, but rather fail in orientation towards the problem
(not knowing how to recognize problems or see problems where there are none, making
inappropriate attributions about them, valuing them). as threats and feeling frustrated and
disturbed when encountering problems, not believing in one's own ability to solve them, not
Anxiety disorders
CAMPUS
UNIVERSITY
dedicating enough time and effort to them and maintaining a point of view
Anxiety disorders
CAMPUS
UNIVERSITY
pessimistic about the results; that is, in general, the initial affective, cognitive and behavioral
reactions to problems).
Therefore, they recommend emphasizing the latter and briefly reviewing problem-
solving skills. In any case, the intervention to be adopted should depend on the needs of each
patient.
Another point made by Butler is that the patient must not only be able to identify and
define the problems and determine if he can do something about them, but he must also
decide when to carry out the problem-solving process and, once Once the solution has been
decided, when will it be applied? If, until these moments arrive, more concerns arise regarding
the problem, then the patient should let them go, remind himself that now is not the time, and
engage in some type of attractive or attention-occupying activity (e.g., a hobby, music, etc.).
exercise, conversation, positive imagination).
DISORDER RELATED TO STRESSORS AND TRAUMATIC EVENTS
1. DIAGNOSTIC GUIDELINES FOR RE and A DISORDER. TRAUMATIC (PTSD) BY DSM-V 13 .

2. THE FOA AND ROTHBAUM PE/CR TREATMENT PROGRAM (1998).
These authors include 3 CBT programs with more
or less therapeutic components depending on
the symptoms presented by the patient. Program
1 would be the treatment of choice for PTSD,
being the simplest and easiest for therapists and
patients. For its part, Program 2 incorporates the
Cognitive Restructuring component and is
Anxiety disorders
CAMPUS
UNIVERSITY
recommended for
patients whose main problem is dysfunctional thoughts that produce guilt and shame and
in people who present other comorbid anxiety disorders.
Anxiety disorders
CAMPUS
UNIVERSITY
Finally, Program 3 includes various techniques that are part of Stress Inoculation Training,
such as, for example, Self-Instruction Training or Progressive Muscle Relaxation. The
authors recommend this broader multicomponent program for patients who suffer
extreme and continuous tension and who, consequently and as mentioned in the previous
section, reject exposure until arousal decreases to more bearable and manageable levels.
In this section we will focus on Program 2 . The treatment protocol is made up of a
variable number between 10-12 90-minute sessions. Depending on the specific needs of
each patient, the clinician will finish the program in session 10 or may consider the
convenience of doing 1 or 2 additional sessions to practice a particular component and/or
consolidate the changes. The main therapeutic components included are Psychoeducation,
breathing training, Cognitive Restructuring, imagination exposure and live exposure .
Additionally, as is the case in most CBT programs, it includes a psychoeducation component
at the beginning, a small relapse prevention component at the end, and homework
throughout the entire therapeutic process.
^ Educational component . This component begins to be introduced in Session 1 in which the

patient is presented with the logical basis of the program, analyzing the treatment
strategies that will be used in the program and explaining that the treatment objective is
post-traumatic stress symptoms. The other part of this first session is evaluation since it is
dedicated to collecting relevant information about the traumatic event, which will be
useful for subsequent EP sessions in imagination.
On the other hand, much of Session 2 is spent educating the patient about the
symptoms of PTSD. The educational component in this second session includes, on the one
hand, an explanation about common reactions to a traumatic experience (e.g., fear,
anxiety, flashbacks, nightmares, concentration problems, increased physiological arousal,
withdrawal behaviors). avoidance of everything that reminds us of the traumatic event,
negative and intense emotions of sadness, guilt, shame, anger, etc.) emphasizing the
manifestations that the patient presents and that have been evaluated
Anxiety disorders
CAMPUS
UNIVERSITY
previously. And, on the other hand, the Theoretical Model of PTSD is introduced, which
integrates all these reactions and shows how PTSD develops. This model conceptualizes
PTSD as a failure to adequately process the memory of the trauma due to extensive
avoidance of thoughts and situations that remind us of the traumatic event. These
avoidance behaviors maintain the erroneous negative beliefs that the person has about
oneself (“I am unable to cope with stressful situations”) and the world (“The world is
dangerous”) and that prevent the emotional processing of what happened.
^ Breathing Training . The objectives of breathing training are for the patient to learn to
reduce their breathing speed and the amount of oxygen in their blood so that, with
practice, they are able to reduce anxiety. The component is introduced by explaining to the
patient how the way we breathe affects how we feel, showing the effect that
hyperventilation has on anxiety. This component is introduced in Session 1 with the
purpose of providing the patient with a strategy from the beginning of treatment to reduce
the very high levels of anxiety that people who suffer from PTSD usually experience by
simply telling what happened in the problem evaluation phase. .
The training consists of taking a normal breath, saying the word calm or relax to
yourself while exhaling and pausing for a count of 4 before taking another breath. This
training is repeated 10 to 15 times. Towards the end of the year (approx. 9 breaths) the
instructions are stopped while the patient continues practicing. At the same time, the
patient is instructed to observe his chest or abdomen so that he can follow his natural
breathing rhythm. At the end, you are given an instruction sheet and asked to repeat the
training as homework at least twice a day.
^ Cognitive Restructuring . As a result of a traumatic experience, a person's perspective on

themselves and the world can undergo a drastic change. Specifically, the person may
perceive themselves as unable to face and manage stressful situations and the world as a
dangerous place. It is also common for the person to believe that the traumatic event
occurred because of their fault and that they
Anxiety disorders
CAMPUS
UNIVERSITY
He deserves what has happened to him. The objectives of Cognitive Restructuring are to
reduce anxiety or emotional distress through the identification, evaluation and
modification of dysfunctional beliefs. This component aims to help the patient develop
new, more realistic beliefs about their ability to cope and about the safety of the world in
general and the situations related to the traumatic event in particular. It is important to
explain to the patient that the Cognitive Restructuring technique requires effort and
collaboration between patient and therapist. Dysfunctional thoughts and beliefs are
treated as hypotheses and the therapist and patient will work together to gather evidence
to determine whether the patient's hypotheses about himself, others, or the world are
accurate and useful to him. The Socratic questioning method is used to help the patient
evaluate and modify their negative beliefs.
Homework consists of completing daily records, in which the patient has to identify the
triggering situations, the emotions they have experienced in these situations, and the
negative thoughts and beliefs behind these emotions. The patient then has to challenge
these beliefs and generate alternative, more rational beliefs. This component is introduced
in Session 3 , in Session 4 the practice continues with the therapist and, starting in Session
5, it is part of the agenda of all sessions until the end of the treatment along with the EP
component in imagination ( Sessions 5-10).
^ Long Exposure in Imagination . Taking into account the theoretical model of PTSD discussed
above, the goal of PD is to promote emotional processing through the deliberate
systematic confrontation of stimuli related to the traumatic event.
Confrontation with the memories of the trauma will allow the memories connected to
the episode to be processed, causing the patient to relive them for a long period of time.
Specifically, reliving the episode will have a series of positive consequences for the patient:
1) It will help your anxiety and fear levels decrease through the process of
habituation.
Anxiety disorders
CAMPUS
UNIVERSITY
2) You will learn that “remembering” is not the same as “reexperiencing” the episode.
3) You will realize that you will not lose control or go crazy if you “involve” yourself in
the traumatic experience.
4) You will increase your personal competence and sense of self-control.
5) It will help differentiate the traumatic event from other events associated with it
but that are not dangerous.
6) It will prevent avoidance from being negatively reinforced.
7) It will incorporate safety information into traumatic memory.
8) It will help reaffirm that the traumatic event was something concrete and specific.
9) It will increase the perception of oneself as capable and brave.
10) It will generate a more organized memory record, easier to integrate with the rest
of the memory system. Exposure in imagination (repeatedly remembering and
recounting the traumatic event ) followed by a restructuring of said experience of
reliving the event (processing) are used simultaneously with the aim of
disconfirming the erroneous beliefs that underlie PTSD.
This component is introduced in Session 4 and, starting with Session 5, it is part of the
agenda of all sessions until the end of the treatment along with the Cognitive Restructuring
component (Sessions 5-10).
5 Live exhibition . Exposure can also be made to real-life situations, objects, or people that
remind you of the traumatic event. In vivo exposure tasks aim to address the
misperceptions presented by PTSD patients that certain stimuli that are safe are seen as
dangerous and, therefore, should be avoided; about how their anxiety will last forever if
they stay in the situations related to the traumatic event instead of escaping from them
and; about the fact that they are incapable of facing stressful situations and situations that
cause them discomfort. Consequently, live exposure exercises typically include gradual and
systematic approaches to situations that the person
Anxiety disorders
CAMPUS
UNIVERSITY
perceived as dangerous (e.g., going out in the afternoon with friends) and situations that
the person avoids not because they are dangerous but because they remind them of the
traumatic event and cause a lot of discomfort and they do not believe they are able to
tolerate it (e.g. ., see news about the war in Afghanistan). This component is introduced in
Session 2 and, unlike treatment protocols for other anxiety disorders, live exposure is
rarely practiced in session but is usually assigned as homework to allow sufficient time. in
session for the EP in imagination.
OBSESSIVE-COMPULSIVE AND RELATED DISORDERS
1. DIAGNOSTIC GUIDELINES FOR OBSESSIVE-COMPULSIVE DISORDER BY THE DSM-V 14 .

2. THE COGNITIVE MODEL OF OBSESSIVE-COMPULSIVE DISORDER: THE MODEL OF
SALKOVSKIS AND WARRICK
(1988). Throughout his development, the patient learns a series of
cognitive schemes related to rules regarding correct
behavior and responsibility. These schemas are activated
by certain critical or specific events related to them, which
lead the patient to develop a normal obsession about
their responsibility in those events (concerns,
ruminations that, when persisted, trigger
a series of negative automatic thoughts (also related to responsibility). These negative
thoughts try to be neutralized by the patient, resulting in obsessions and/or compulsions.
Anxiety disorders
CAMPUS
UNIVERSITY
COGNITIVE MODEL OF OBSESSIVE-COMPULSIVE DISORDER
PERSONAL HISTORY AND BIOLOGICAL FACTORS(1)------------ COGNITIVE SCHEMES (2)

Problems and punishments for "not having strict rules for correct conduct or morality, enough
care with what one does."
Strict rules on conduct and responsibility.
CURRENT TRIGGER EVENTS (3)------------------------- COGNITIVE DISTORTIONS (4)

Critical incident. Should/Blame.
RESULTING INTERACTIVE CIRCLES

Thought-------------------------Affect/Physiological Activation--------------------Conduct
Guilt/Responsibility Anxiety avoidance behavior
Disorder of dream Rituals/Compulsions
"NEUTRALIZATION" Change in body functions
OBSESSIONS Depression, etc
Cognitive Rituals/Rumination/Etc.
3. THERAPEUTIC OBJECTIVES .
5 Reduce or eliminate the intensity/frequency of
obsessive and/or compulsive symptoms and the
discomfort associated with them.
^ Develop in the patient a series of cognitive-behavioral
skills so that he can face his obsessions-compulsions.
^ Modification or relaxation of rigid rules on morality
and responsibility
Anxiety disorders
CAMPUS
UNIVERSITY
underlying conditions that make the patient vulnerable to this disorder (cognitive
schema).
4. EVALUATION QUESTIONNAIRES. We refer to some examples:
Anxiety disorders
CAMPUS
UNIVERSITY
1) Maudsley Obsessive-Compulsive Behavior Inventory (MOCI; Hodgson and

Rachman, 1977): It contains 30 items that the patient answers based on their
presence or absence (yes/no). It allows a global score, and four subscales referring
to the four most frequent types of obsessions-compulsions: checking, washing,
doubt and slowness.
2) Compulsive Activity Checklist (CAC; Philpott, 1975): It has a four-point scale for
each item, and refers exclusively to compulsive behaviors.
3) Leyton Obsession Inventory (Cooper, 1970): Contains 69 items. It allows the
evaluation of obsessive symptoms and the presence of obsessive personality traits.
5. INTERVENTION PROCESS. The therapeutic process for obsessions-compulsions would

follow the following phases:
1) Evaluation and conceptualization of problems :
^ Evaluation of obsessions:
a) External cues: Objects or situations that cause discomfort.

b) Internal keys:
- Upsetting images, thoughts or impulses.

- Body sensations of discomfort. Anxiety.
c) Anticipated consequences of internal/external keys.
- Perceived threat.
d) Strength of the thought system: degree of subjective certainty that what is
feared will happen.
e) Evaluation of possible associated depressive state.
^ Evaluation of the behavioral avoidance system:
a) Preparation of an exhaustive list of rituals and the degree of anxiety that

each of them generates or eliminates (hierarchy of rituals).
b) Detect passive avoidance behaviors: behaviors that the patient develops to
avoid the appearance of harm.
Anxiety disorders
CAMPUS
UNIVERSITY
c) Detect the relationships between fear cues and avoidance behaviors: The
threats or harms that you believe you are avoiding with them.
2) Therapeutic socialization:
^ The relationship between thinking (obsessions and threatening expectation or
"fear"), behavior (rituals and/or other avoidance behaviors) and emotional
state (pe anxiety); the objectives of the therapy, the general procedure and
Self-Registration.
^ The typical Self-Registration usually distinguishes four elements :
1. Intrusive thoughts (obsessions).
2. The underlying negative thoughts or threatening expectations
("Fears").
3. Passive avoidance behavior.
4. The rituals.
5. For example:
- SITUATION: Before going to bed.

- THOUGHT: The gas leaks and explodes.
- INTRUSIVE AND DEGREE OF DISCOMFORT (O-10): Anxiety-9.
- NEGATIVE THINKING OR BASIC FEAR:
o I'm not calm.
o It would be my fault.
- PASSIVE/RITUAL AVOIDANT BEHAVIOR:

o Leave the windows open.
either Get up and close the gas spigot 5 times very
slowly.
3) Intervention: The average treatment usually consists of about 15 sessions. Two
phases can be distinguished in it:
^ Intensive Phase: The ideal is to have 3 sessions per week of 45 minutes to 3
hours in duration; where live or covert exposure is used. The period usually
Anxiety disorders
CAMPUS
UNIVERSITY lasts 3 weeks (9 sessions).
Anxiety disorders
CAMPUS
UNIVERSITY
5 Development Phase : Weekly treatment continues, preferably in a group format,

for secondary disorders (6 sessions). These sessions would be dedicated to
modifying the patient's rigid lifestyle, after the symptoms disappear, to working
on other associated problems and to maintaining achievements (exposure to
new problems).
Since the fundamental component of the treatment is exposure, one might
ask: What does Cognitive Therapy contribute to behavioral techniques
(exposure-response prevention)? The answer would be:
1. The postulation of a cognitive system underlying obsessions-
compulsions, which would explain their development and the patient's
vulnerability to suffering from this disorder.
2. Facilitate the use of behavioral techniques.
3. Work on resistance to treatment.
4. Treatment of associated depressive states or ideation.
5. Facilitate cognitive reappraisal of threat predictions.
6. Modification of the most common personal assumptions (eg
responsibility, security).
7. Work with pure obsessions.
6.1. THERAPEUTIC RULES FOR WORKING WITH OBSESSIONS:
1. Questioning the probabilities of fear: The patient usually confuses possibility
(possible in general) with probability (low). The therapist explains the difference
and uses it ("How likely is that to happen?" "You think about it many times, and
how many times did it happen?"). The patient asks himself the same question as
homework.
2. Consequences of maintaining fear : "Does it help you at all?", "Does it really
matter to you, and does it really matter?"
3. Distracting Techniques: The patient is taught to stop his obsessions and think
Anxiety disorders
CAMPUS
about
UNIVERSITY other things (eg stopping thinking and using cards with alternative thoughts
or images).
Anxiety disorders
CAMPUS
UNIVERSITY
4. Reattribution of blame: "Would he be the only one responsible? Could there be

other factors that intervened?"
5. Restructure defensive reasons for resistance to therapeutic intervention: For
example, use of advantages and disadvantages.
6. Use of the downward arrow to detect Personal Assumptions (See section on
Agoraphobia) .
7. Exposure and Response Prevention: Covert exposure is used by recounting scenes
related to the obsessive components (information from Self-records can be used).
The patient is made to adopt a relaxed posture and the scene is described. Every 5
minutes you can be asked about the level of anxiety (eg from 0 to 10). Exposure
intervals less than 30 minutes and more. You can record the presentation session
as homework. Prevention involves not avoiding the scene. It is the essential
technique to use with obsessions.
6.2. THERAPEUTIC RULES FOR WORKING WITH COMPULSIONS:

1. Same as above with obsessions and...
2. Response prevention: In situations that elicit rituals, prevent the response,
preventing the ritual. Subjective anxiety levels are noted; pe every 5 minutes.
Likewise, intervals longer than 30 minutes are the most effective in achieving
greater habituation of the associated anxiety.
3. Prevent passive avoidance: The same procedure as above is followed.
4. Typical rules for response prevention:
• Checkers: Only one question or check is allowed.
• Cleansers: Only a weekly shower and a short hand wash before each meal
are allowed during treatment.
6.3. MANAGEMENT OF FREQUENT TREATMENT DIFFICULTIES:

1. The instructions are not followed: The patient is asked to explain the
reasons (reasons) and these are restructured (eg request for evidence,
Anxiety disorders
CAMPUS
UNIVERSITY
balance of advantages-disadvantages, etc.) or the treatment is cut off at a

termination point (eg if the patient has other priorities).
2. Symptom replacement: The most common is the appearance of new
passive avoidance behaviors. These are usually:
a) Ask for great assurances from the therapist.
b) Lengthen sessions as an insurance measure.
c) Emergence of new passive behaviors. The therapist may indicate that
these maneuvers respond to an increased need for security and the
disadvantages of responding to them. You can also restructure the
reasons associated with these maneuvers.
3. Emergence of new obsessions: Attention is paid to a reactivation of
personal assumptions. The indicated thing is to work on modifying them.
4. Altered family system in relation to the problem: Work is carried out in
parallel with the couple or family.
5. Asymptomatic patient but with a rigid lifestyle: We work with gradual
increments of modification of activities (eg domain-like activities,
restructuring of leisure-work time, etc.).
6.4. WORKING WITH DISTORTIONS AND PERSONAL ASSUMPTIONS:

1. Typical personal assumptions: The search for absolute security and
responsibility is common to these patients. A system of thought without limits
and end in its scope. The therapist's purpose is to teach the patient:
• Impossibility of absolute security regarding any future event.
• The unproductivity and uselessness of guilt, as well as the use of causal

reattribution in any unintentional act.
2. Catastrophic Maximization: The patient gives excessive importance to
particular thoughts and then falls into the cognitive trap of searching for their
origin (e.g. "Killing my son crosses my mind, it can't be!...Why
Anxiety disorders
CAMPUS
UNIVERSITY
What will I think of this? Could it be... or could it be because...?"). The therapist
informs the patient that the mind contains streams of these types of thoughts,
that it is "natural" for them to ever appear, and that there is no point in
searching for their origin.
3. Self-fulfilling Prophecies : The patient is in expectation of possible threats. As
unpleasant events happen, in fact; the patient reaffirms his attitude of
"keeping an eye on them." The therapist explains to the circle and points out
that the alternative is to accept future insecurity.
6.5. FIELD OF APPLICATION OF COGNITIVE THERAPY:

1. Facilitation of exposure and prevention of responses: A series of cognitive
techniques are used to explain to the patient their problem (eg thought-affect-
behavior relationship) and thus facilitate breaking the "vicious circles" through
exposure-prevention of responses.
2. Exposure with patients with overvalued ideas: First, the patient's cognitive
predictions are detected and contracted with the exposure-prevention task of
SR (As a "personal experiment").
3. Facilitation and reevaluation during the exposure : During the exposure,
intrusive thoughts are questioned.
4. Treatment of associated Anxiety-Depression problems .
5. Work with cognitive schemes : Causal reattribution and cognitive alternatives
(predictive, interpretive) are used above all.
6. Facilitation of work with Ruminations (Cognitive Prevention is used) :
Ruminations are voluntarily provoked, using a hierarchy from least to greatest
associated discomfort, and the patient questions the associated automatic
thoughts and uses behavioral alternatives (eg prevention of RS). The down
arrow is used. For example: CHAIN OF RUMINATION-ASSOCIATED ANXIETY (0-
Anxiety disorders
CAMPUS
UNIVERSITY 10)/ ALTERNATIVES.
Anxiety disorders
CAMPUS
UNIVERSITY
The case of a patient (doctor) with obsessive ruminators is presented regarding

her fear of radioactive contamination.
Obsessive Fears (Downward Arrow)--------------------------------- Alternatives
1. Answer: "Food from the supermarket is contaminated when passing
through the photoelectric cell" (5).
- "What would happen if it were like that?"

Alternative 1: "The amount of radiation is minimal" (3).
2. Answer: "I could contaminate my family" (6).

Alternative 2: “ So far I have no evidence of this" (2).
3. Answer: "They could get sick and have to be hospitalized" (8).

Alternative 3: "Idem as above. I think about it but it doesn't happen"
(2).
4. Answer: "They could die" ( 9-10).

Alternative 4: Idem (2).
7. CLINICAL CASE:
1) Identification data :
- 23 year old woman. Confectioner. Single woman.

- Referred by GP for treatment.
• Since relations with her current partner began, for two months she has
continually had doubts about whether she really loves him. A few days ago she
found out that her boyfriend was suffering from epileptic seizures, increasing
her doubts.
• She says she loves her boyfriend, but that doubts come to mind that
Anxiety disorders
CAMPUS
UNIVERSITY continually torment her and that she considers absurd ("His hair is going to fall
out", "He's going to get fat"). Prolix, she has to tell everything to stay calm. She
demands some advice from us, "because it calms me down."
Anxiety disorders
CAMPUS
UNIVERSITY
Internal restlessness, anxiety. "I have gotten into the mania for beauty and
feura." When she is with her boyfriend she compares his and her own physical
appearance with that of others. "Sometimes like two people, one wants to think
about it and the other doesn't. "Many times I have discomfort in my head when
I think about it."
3) Symptoms:
• Cognitive:
■ Images of the groom's head with little hair.

■ Images of her bald boyfriend, with a belly and her not very "photogenic" in
a
photo of both.
■ Rumination, almost all day, "If I had more hair."

■ He cares about physical appearance, but it seems absurd to think about
those things most of the day.
• Affective:
■ Sadness. Worse when the idea is repetitive.

■ Anxiety in relation to rumination.
■ Guilt for wishing the boyfriend was more handsome.
• Motivational: You see it as absurd to think about your ruminations and you
want not to do it, without success.
• Physiological:
■ Sore.
■ Gastralgia.
■ Fatigue in legs.
❖ Behavioral:
■ He asks his family a lot if what is happening to him is normal. They
temporarily reassure him, telling him no.
■ Discords with their parents. "They are very old-fashioned. For example,
they don't want me to go out of town with him. Problems with his boss
Anxiety disorders
CAMPUS
UNIVERSITY due to union demands.”
❖ She previously had a boyfriend (5 years ago) with whom she decided to break
off the relationship when she found out that he was diabetic. A friend told her
that living with
Anxiety disorders
CAMPUS
UNIVERSITY
a diabetic person was very difficult. She experienced intense anxiety thinking
about what could happen. The anxiety was so intense that he went to the
outpatient emergency department. Despite this fear, she continued the
relationship, but when her partner told her one day that she had had a low
blood sugar, an "obsession" awoke in her that something bad could happen to
her partner and she locked herself in the house without wanting to see him. He
had a decisional conflict: On the one hand "he wanted it" and on the other "he
thought he didn't want to be like this (with a diabetic) all his life."
■ He told his partner that he wanted to break up and the reasons for it. His
partner "did not accept" this decision well, although the breakup
occurred. She felt guilty and depressed about this decision. From this
moment on, she was treated with various antidepressant medications
for four years until she was referred to our service.
• Previous treatment with private psychiatrist with medication. Last year in
treatment in our service for a depressive-obsessive problem, receiving
treatment from a fellow psychologist. The results of this period led him to
recover from his depressive state and reduce the intensity of his obsessions.
Subsequently, I continued the case due to internal redistribution of the demand
in the service.
❖ Previous pharmacological treatment, in our service, along with psychological

treatment, with: Anafranil 75 (1/2-0-1/2), Hializan (1-1-1). At the beginning of
the current consultation without medication.
❖ Pregnancy, childbirth and normal psychomotor development. Schooled from
five to fifteen years old. He finished primary school and vocational secretarial
training with good grades. Menarche at 12 years old.
❖ She has had a boyfriend for two months. Her boyfriend is a traveler and has a
permanent job. Good relationships (except for obsessions). Before, he had
another partner (see history of the problem).
❖ He suffers from a stomach ulcer.
Anxiety disorders
CAMPUS
UNIVERSITY
❖ Lives with his parents. The 55-year-old father, a bricklayer. He has had no
relevant somatic or mental history. His 51-year-old mother, a housewife, with
no relevant history, although "somewhat nervous." He has two siblings: a 28-
year-old sister, married and living here, and a 13-year-old brother who is
studying high school and lives with them. Their maternal grandfather also lives
with them. Occasional arguments with his parents over "customs" regarding
dating: he considers them very old-fashioned.
❖ He works in a clothing factory. He has usually represented workers in their
labor demands, which has led him to have certain problems with his boss.
6) Diagnosis: Obsessive Disorder. No compulsive component.
7.2. FUNCTIONAL-COGNITIVE ANALYSIS AND CONCEPTUALIZATION OF PROBLEMS. In relation

to the obsessive problem, it was detected:
• Personal history : breakup with the previous partner with internal and total attribution
of fact, valued as "immoral" (guilt). Amb. “moralistic” family.
• Frequent triggering situations for obsessions:
■ External: waking up in the morning, breaks at work, after meals, seeing your
boyfriend after the day before, seeing someone fat and/or bald.
■ Internal: think about the future of the couple's relationship.
❖ Cognitive distortions and automatic thoughts:
■ "He's going to get fat. If he gets fat I might stop loving him" (Catastrophic
Vision).
■ "And if the same thing happens to me again, and I leave him (like the other)"
(Catastrophic Vision).
■ "I shouldn't think about that" (Should/Blame).
■ "If I look at other men, does that mean I might not love my boyfriend?"
(Polarization-Arbitrary Inference-Maximization).
❖ Cognitive schemes/Personal Assumptions (hypothesized from the "downward arrow"
from automatic thoughts; e.g. What would happen if he got fat and you left him?): "I
have to be very sure that things are not going to happen to me."
Anxiety disorders
CAMPUS
UNIVERSITY
bad. It will be horrible if they happen. If they happen it's my fault. "I have to be very
attentive to the danger advice that others tell me."

> Session #1 and #2:
■ Clinic history. Functional-Cognitive Analysis and conceptualization of problems.

■ Explanation of how the problem works: Obsessive ideas-Fight against them to
forget it-Temporary reduction-Stronger obsessive ideas and associated fears
(automatic thoughts).
■ Explanation of exposure, "Enlargement" mode: "When the obsessive idea comes to
you, imagine, instead of avoiding it, that your boyfriend's belly continues to grow,
his belt breaks, he occupies a room, he bursts the walls,... he occupies the universe
". A rehearsal is done, he ends up laughing.
■ Homework: Expansion.
> Session No. 3:
■ He reports feeling better with the enlargement.

■ We address catastrophizing and guilt for leaving your previous partner. We use
dedramatization and retribution of blame.
■ New essay in extension consultation.
■ Homework: expansion, retribution of guilt for past memories.
> Session No. 4:
■ It continues to feel better with the expansion. Less obsessions.

■ Lower levels of anxiety in Self-Registrations after expansion.
> Session No. 5:
■ Same as previous session.

■ Homework: expansion in the presence of the groom.
^ Session nº 6: Does not attend the appointment.
> Session No. 7:
■ He reports having felt good about the expansion. But then the obsessions increase
Anxiety disorders
CAMPUS
after seeing her boyfriend "with a double chin."
UNIVERSITY
Anxiety disorders
CAMPUS
UNIVERSITY
■ Retelling of previous history with the other couple. Theme of guilt and fear of
disapproval. I reintroduce remuneration. T. house= Expansion and remuneration.
= Session No. 8:
■ Favorable evolution.
■ Worried that her boyfriend will not understand the assigned task. He wrote a letter
for him begging for his collaboration.
■ Other themes: Fear of disapproval (criticism from her boyfriend for her previous
relationship and from her parents for her outings outside their norms). We use
Rational-Emotive Imagination: Imagine the scene of criticism, anxiety response
intense, detect cognitions; idem of imagine scene but
responding only with concern, detect cognitions. We distinguish catastrophizing for
being disapproved of from discomfort for the same (along the lines of Ellis's RET).
■ T. house= Expansion, retribution and Rational Emotive Imagination. (I WILL GO).

= Session No. 9:
■ Favorable evolution persists.

F Session No. 10:

■ We include distracting techniques after expansion.
^ Session #11:
■ We record stimuli and obsessive thoughts for exhibition.

■ T. house = Spontaneous obsessions-expansion, preparation-programmed exposure.
Remuneration and IRE
^ Session nº 12: Same as previous.
^ Session nº13:
■ Relapse. Memories of when her boyfriend was thicker.

■ Introduction of "downward arrow" and questioning (from catastrophic fears to the
Idea of absolute security/guilt).
Anxiety disorders
CAMPUS
UNIVERSITY
■ Sleep insomnia appears: I indicate stimulus control (if it takes more than 15
minutes to fall asleep, leave the room, read, do not return until you have
dream).
^ Session #14:
■ The relapse persists. Hopelessness regarding the evolution of your problem. We
use data from previous evolution. "Relapse Process/Larger Intervals, Now."
■ Adofen 1-0-0 (support) is prescribed.
■ T. house=Idem.
F Session No. 15:
■ Relapse persists. Frequent obsessive ideas.

■ Review cognitive techniques.
■ Covert exposure. Periods of 45 minutes minimum.
^ Session #16:
■ Favorable evolution.
■ "I'm able to be around my ex-boyfriend without having anxiety."
■ We address personal assumption. Impossibility of total security.
■ T. house=Idem. Review in a month. He has stopped the medication.
^ Session #17:
■ Very favorable evolution. In just one month, one day he experienced slight
discomfort.
■ You want to be discharged. You think you can handle your problem.
■ We review possible risk situations (eg couple breakup), she accepts insecurity as
part of the relationship and co-responsibility rather than sole responsibility. High.
Anxiety disorders
CAMPUS
UNIVERSITY
- OBSESSIVE-COMPULSIVE DISORDER -
For Salkoviskis and Kirk the basic principles of treatment are the following:
1. Deliberate exposure to all previously avoided situations.
2. Direct exposure to feared stimuli (including thoughts).
3. Prevention of compulsive rituals and neutralizing behaviors, including covert ones
(i.e., response prevention).
We are going to differentiate two types of treatment depending on whether motor
rituals occur in obsessions or not . We will address the first ones first.
The main technique that will be used in the treatment is Exposure and Response
Prevention . This technique consists of exposing oneself to feared situations by eliminating
rituals or reassuring behaviors. The main fear of people who have to expose themselves to the
stimuli they fear is facing anxiety, therefore, it is essential to explain to the patient the anxiety
curve, that is, how in the first moments they will feel how anxiety increases, but there comes a
time when it remains, and then begins to descend and finally disappear. It is necessary to warn
you that the first time you face the situation, it can last between 30 and 60 minutes, although it
may be less, it all depends on the person, as you are exposed the time will decrease, until you
reach exposure. when anxiety completely disappears.
Before starting this technique, you must build a hierarchy of feared situations, ordering
them according to the degree of discomfort and the rituals they produce, for example, listing
them from 0 to 10. Within these situations, steps can be established.
Once the hierarchy has been established, but
before facing the exposure, it is necessary for the
patient to identify the blocking behaviors they use, that
is, those behaviors they perform voluntarily to be safe
and reduce discomfort.
Once these steps have been carried out, you
can move on to the exhibition, which must be carried
Anxiety disorders
CAMPUS
UNIVERSITY
out
Anxiety disorders
CAMPUS
UNIVERSITY
when the patient has enough time. You will have to choose the first item in the hierarchy,
identifying what insurance behaviors you performed, so as not to do them when exposed. It is
very important to emphasize this point, that you do nothing to reduce anxiety when exposed
and that you remain in the situation for the necessary time, writing down, for example, every
10 minutes, what your anxiety level is.
Depending on the rituals that the patients present, this technique can be used in
different ways. For example, if the person is obsessed with order, those objects can be
disordered, and the person may expose themselves by seeing that disorder. Or also in the case
in which the person performs verification rituals, do not perform them and check what is
happening.
Exposure sessions should ideally be carried out daily, until anxiety has decreased for
the same item in the hierarchy and as items are surpassed, move on to the next.
Another form of exposition is that which is carried out in imagination. To apply it, the
patient must have a great imaginative capacity, which, once reproduced in their mind,
produces the same discomfort as if it were real. It is usually applied when the live exposure is
complicated, the procedure being the same for both types of exposure.
Regarding the treatment of obsessions without motor ritual, although exposure will
also be used as a technique, on this occasion instead of situations it will be applied to thoughts.
First of all, the patient will have to create a hierarchy of thoughts, as they appear in his
mind. Once built, the covert rituals are identified, although sometimes it can be complicated,
since both obsessions and rituals are thoughts and when it comes to differentiating them it can
be complicated.
For the first exposure session, the patient must have enough time, get comfortable,
close his eyes and create the first thought in his mind. Once you have them, the presentation
begins, in which you will have to write down the levels of anxiety you experience. The criterion
to move on to the next item will be the same as in the previous case, that the anxiety level is
zero and there have been no ritualizing behaviors.
A very important part of the therapy applicable both when motor rituals exist and
Anxiety disorders
CAMPUS
UNIVERSITY
when they do not, is cognitive therapy, specifically cognitive discussion. This
Anxiety disorders
CAMPUS
UNIVERSITY
It will help us to test the ritualizing thought that the person has: for what purpose they do it, if
it is proven that using it does not fulfill their fear, what use it has, etc. Let's look at an example:
Thought to discuss: “If I don't check that I have locked the car 4 times, they will rob me.”
Possible discussion questions:
• What is the real probability of this happening?

• How many times have you feared it and how many times has it happened?
• Do you think everyone checks 4 times if they have locked the car?
• What would happen if you only checked it once?
EXAMPLE OF IMAGINARY EXPOSURE SEQUENCE FOR TESTERS

(Taken from Cruzado, JA). 15 Sessions.
The imagination treatment sequence that was carried out with the patient was as
follows.
1. You are asked to imagine that you have refused to

check the gas and lights and consequently a fire has
broken out during the night, destroying your house.
2. He is asked to imagine that he has scrubbed the sink
without looking and discovers that he has drowned a
small pet in the sink.
3. You are asked to imagine that you leave the basement door open and your
daughter falls down the stairs, suffering serious injuries.
4. You have to imagine that you are carrying your daughter in your arms and
because you are not careful you trip and fall on top of your daughter, causing
serious injuries and hospitalization.
Anxiety disorders
CAMPUS
UNIVERSITY
5. You have to imagine a scene where you are driving on a highway and are stopped
by the police, who accuse you of hit and run.
The exposure is carried out throughout the treatment. When habituation to one scene
occurs, the next is introduced.
RULES IN RESPONSE PREVENTION
Anxiety disorders
CAMPUS
UNIVERSITY
Below we will explain what types of issues are allowed and which are not, in response
prevention, depending on the group of obsessives in question.
^ Cleansers: These patients are not allowed to use water on their own body (no washing
hands, showering, using towels, etc.). Yes, they can use creams or toiletries, but not objects
that reduce contamination. Response prevention must be supervised by family members or
people trained for this purpose, who will be the ones who try to prevent the established
guidelines from being broken. The time spent in the shower must be limited.
^ Testers: They are not allowed to perform any testing rituals. Also in this case , response
prevention must be carried out by people who live with the patient, who will inform the
therapist of progress and setbacks. In cases where the patient is highly motivated, the
figure of the supervisor can be eliminated, but to do so, the situation must be carefully
evaluated.
HYPOCHONDRIA
1. DIAGNOSTIC GUIDELINES FOR HYPOCHONDRIA BY THE DSM-V15 .

2. COGNITIVE MODEL OF HYPOCHONDRIA: THE KELLNER MODEL (1991).
Basically, Kellner's model is based on the
idea that the patient has developed a
cognitive scheme about the belief of having
a physical illness or the possibility of
developing it based on certain physical
signs. This scheme would have been formed
carried out observational learning

Anxiety disorders
CAMPUS
UNIVERSITY
from a socio-familial context where the patient would have been exposed to family models
with illnesses and would have
("identifying imitation"). I could also
Anxiety disorders
CAMPUS
UNIVERSITY
having been exposed to different and atrogenic factors such as the achievement of
reinforcements (attention, avoidance of responsibilities, etc.) unnoticed by their
environment (healthcare, family...) from erroneous diagnoses of detected diseases.
Likewise, the patient, when exposed to his own or others' illnesses, could have learned
selective perception, paying attention to signs of physical change and attributing these
changes to physical illness. This cognitive scheme would be "activated" by certain internal
sensations (normal bodily processes such as physiological changes associated with
digestion, breathing, physical fatigue, etc.; minor pathological processes such as tension
headaches, dyspepsia, abdominal cramps, etc.; emotional variations such as anxiety,
sadness, anger, etc., and external stimuli such as news or information about illness and
related topics). The activation would produce a selective processing of information
(Selective Abstraction) focusing on unpleasant internal and external signals and focusing
attention on them and making threat interpretations about them (Catastrophic Vision: fear
of the consequences of discomfort).
The result would be a feeling of real personal discomfort, attributed by the patient to an
illness. The resulting vicious circle would be: the patient observes a bodily sensation
(selective perception), wrongly interprets it as a sign of illness, other thoughts-fears are
triggered regarding the consequences of the illness, death..., an increase in sensations
occurs. body and the associated anxiety, performs security-seeking behavior (check-ups,
reassurance) that produces an effect of temporary tranquility.
COGNITIVE MODEL OF HYPOCHONDRIA
Learning history and biological factors (1) ----------------------- Cognitive Schemes (2)
Role of family learning models Belief of suffering or threat of
with diseases and observational learning suffer it
Iatrogenic factors: inadvertent family and health reinforcement, erroneous diagnoses.
Learning selective perception after having suffered an illness or observing it in
Anxiety disorders
CCAMPUS
U NI SEE SITÁ
others
CURRENT TRIGGER EVENTS (3)-------------------------------- COGNITIVE DISTORTIONS (4)
Internal signs: Catastrophic vision.
Normal body processes Selective abstraction.
Minor pathological processes.
External signs:
Information related to diseases.

Thought--------------------------------Affect/Sensation---------------------------Conduct
Apprehension/Fears Body sensations. Medical checkups.
Attribution to illness. Anxiety Depression.
Passing tranquility.
Body self-observation.
1 Reduce fear of illness and death.
59 Reduce symptoms and sensations of physical discomfort.
60 Reduce anxiety and/or associated depression.
59 Improve the patient's understanding of symptoms.
59 Modify the cognitive base: Belief that one is sick, selective
attention to bodily changes and threatening
interpretations linked to normal or temporary bodily
changes.
4. EVALUATION QUESTIONNAIRES. We mention as relevant examples:
Anxiety disorders
[219]
CCAMPUS
U NI SEE SITÁ
1) The Wolpe and Lang Fear Questionnaire (1964 ): It consists of 122 items referring
to various situations that the patient evaluates based on the degree of
Anxiety disorders
[220]
CAMPUS
UNIVERSITY
aversion that arouses him. It contains items referring to illness, death, and the like.
It can be useful to detect constellations of fears.
2) Illness Attitudes Scale (IAS; Kellner, 1986, 1987): It consists of nine scales, each
with three items-questions that are rated from 0 to 4 (from never occurs to occurs
all the time). . The maximum score for each scale is 12 points. The scales assess :
■ Concern about illness.

■ Concerns about pain.
■ Health habits.
■ Hypochondriacal beliefs.
■ Thanatophobia or fear of death.
■ Phobic disorders.
■ Body concerns.
■ Experienced treatments.
■ Effect of symptoms.
5. INTERVENTION PROCESS. The steps to follow would be:

^ Evaluation and conceptualization of the problems : It would consist of a detailed
clinical history, Cognitive Functional Analysis and conceptualization of the problems.
Fundamentally, it would try to detect the patient's fears of the disease, its historical
origin (personal context, previous treatments), associated cognitions (beliefs,
attributions, expectations of threat), related emotional states (Anxiety, Depression...)
and safety strategies. of the patient (consequent phobic avoidances), as well as the
interpersonal repercussions (attention, avoidance of unpleasant activities, marital
conflicts, etc.). In general, the new scales indicated by Kellner in the IAS can serve as
reference points to conceptualize part of the problems presented.
^ Therapeutic socialization: The therapist would present a model of how the disorder
works (thought-affect/feeling-behavior relationship) understandable at the patient's
level. It would be important for the therapist not to present the problem as "you have
nothing, it's just your imagination", but rather to start from the idea of
Anxiety disorders
CAMPUS
UNIVERSITY
that the patient experiences real discomfort, as real as someone suffering from a
physical illness. An alternative conceptualization could be: "You really have a disease,
that disease basically consists of having a very great sensitivity to the changes that
occur in your body" and showing the patient in person how the problem could develop.
The rest of the process continues with the use of Self-Registration as a way to support
this reconceptualization.
^ Intervention: Therapist and patient generate alternatives to the vicious circles involved
and their cognitive basis, based on the treatment objectives.
1) Functional-Cognitive or Psychological Exploration:
• The vicious circles are repeatedly explained to the patient: Body changes --->
Concentrated attention ---> Fear of illness ------------------> Increased discomfort
bodily.
• Detect the sequences (eg Self-records): Symptoms or Body Signs ----------------------->

Automatic Thoughts (V. Catastrophic, Attributions) ------------------> Increase of
Body Discomfort and Negative Emotions ----------> Calming behaviors
passengers.
2) Information Techniques (Cognitive Reconceptualization):
• Tell the patient that only a small portion of the somatic symptoms people
experience have an organic cause, and that they usually have a good prognosis.
• Explain vicious circles: Symptom ----------------> Misinterpretation ---------------->
Increase in symptom.
• Explain how the patient has been able to learn and maintain his symptoms
based on the data from the Clinical History and the Functional-Cognitive
Analysis. The influences of models or lived experiences, the role of learning to
pay attention, would be explained; and as live examples, the patient could be
asked to concentrate on how he feels the pressure of the seat on his butt, the
Anxiety disorders
CAMPUS
UNIVERSITY tongue on his mouth, the belt or collar on the area of
Anxiety disorders
CAMPUS
UNIVERSITY
respective contact, etc. Other more symbolic examples could be: "Piano tuner
who has learned to identify timbres of very fine tones" and similar.
3) Acceptance and cordiality: The suffering experienced by the patient is accepted as a
real discomfort, but not its causes attributed to organicity. That is to say, you are told
that you suffer from a real, psychological disorder where your personal experience
(learning) and what you think are the causes of it.
4) Use of retribution for discomfort and Decatastrophization: More realistic alternative
thoughts are generated to the bodily changes suffered, de-dramatization of their
predictions based on evidence, distraction, etc.
5) Treatment of Anxiety and/or Associated Depression 15 .
6) Physical Examinations: Collaborate with the patient's doctor so that the physical
examinations performed by the patient are followed by memories of the circle,
accepting the patient's discomfort as a real illness and suffering ( but of psychological
origin). If physical illnesses appear in the patient, differentiate physical illnesses from
mental illnesses.
7) Exposure to phobic fears of death and/or illness :
- See exposure techniques in Phobias.
- Various forms of exhibition:
- Use of fear hierarchies (live/image).
- Descriptive repetition of triggering events (catharsis).
- Directed grief: an account of observed losses-deaths.
- Exposure to topics about the disease (diagnoses, eg).
8) Management of somatic symptoms of discomfort: Distracting techniques such as
physical exercise, relaxation or biofeedback are usually used.
15
It will be seen extensively in the Mood Disorders (Depression) Module.
Anxiety disorders
[224]
CAMPUS
UNIVERSITY
DIFFICULTIES IN EVALUATION16
F The patient has no initiative to speak.
■ This type of behavior usually occurs in the first session in which the
patient only speaks in monosyllables and therefore the therapist has
no information about the patient. In this situation, the therapist
takes advantage of that first session to explain to the patient what
the therapy will consist of in general and explain to him that his role
must be active and participatory, since otherwise
therapy won't work.
^ The patient responds to the therapist's questions in excessive detail and goes from one
ask another .
This is the opposite case to the previous one, in which the
patient wants to give so much information that he does not
know how to do it, which may be due to the lack of habit of
providing information to an unknown person and the novelty
of it. When the therapist observes this situation, he will have to
forcefully cut off the speech, explaining that things will be
discussed exhaustively later,
because if not, they will not be able to advance in the evaluation. Another way to prevent
the person
To tell too much information is by asking closed questions, so that the person has to
respond briefly.
^ The patient continues speaking when the session has ended.
■ Another typical situation that can occur during the evaluation

is that the therapist ends the session, but the patient
continues talking without getting up, claiming that it is only a
moment.
16 The difficulties that may arise during the Evaluation and Treatment were widely addressed in the
Therapeutic Skills Module; We only remember the most frequent difficulties during the Evaluation.
Anxiety disorders
CAMPUS
UNIVERSITY
■ In this situation, the therapist can put the sessions with this/these patients, among
other sessions, so that they understand that other people must be attended to and that
therefore it cannot be extended any further. The therapist can also get up and walk
politely towards the door, inviting him/her to leave and saying that they will continue
the next day. One way to avoid continuing to sit when the end of the session arrives is
to not ask questions when the end is approaching, thus preventing it from going on too
long.
■ It is very important that the therapist has the ability to organize the time of the sessions
and be directive, but without affecting the empathetic relationship he or she has with
the patient.
^ Impatience for the start of treatment.
■ It is very normal during the evaluation that the patient

wants to start treatment as soon as possible and makes
comments about it. In the event that this happens, the
therapist can explain that the evaluation must be
exhaustive in order to provide a
effective treatment. If the problem allows it, the
therapist can
send him homework from the beginning (such as Self-registrations), so that he has
the impression that you are remedying your problem.
■ On these occasions the therapist must be clear in his explanations, adapting the
language at the cultural level of the patients and emphasizing information relevant to
that this has a greater effect on the patient. The tasks that the therapist sends
performed, they must be simple and do not entail a high cost for the patient,
knowing how to motivate him from the beginning to carry out the tasks.
5 Excessive completion of tasks.
■ If the records that are requested in therapy are
completed by the patient with excessive details, there
may be sessions that are expressly dedicated to
commenting on them and, therefore, losing time to be
able to carry out other aspects. In these
cases, the patient is asked to turn in the records the day before the next
Anxiety disorders
CAMPUS
UNIVERSITY
session so that the therapist can see them, but without wasting time in sessions with
the patient.
■ Records may also be requested that require the patient's responses to be quite brief
and specific.
■ In these situations, the therapist must know how to select the final behavior of the
successive approaches, knowing how to choose the appropriate reinforcements. You
must also be able to identify obstacles that may appear.
^ The topic discussed is similar to the situation experienced by the therapist.
■ On some occasions the therapist may be affected by the cases

that come to his consultation. There are times when the
problem raised by the patient resembles the situation that
the therapist is experiencing. Given this, he must know how
to differentiate between his personal actions and the
professional, looking for strategies that facilitate a change in
its interpretation
problem staff.
Anxiety disorders
CAMPUS
UNIVERSITY
gi
ve
Anxiety disorders
CAMPUS
UNIVERSITY
PHARMACOLOGICAL TREATMENTS17
Anxiety as an adaptive defense mechanism gives rise to psychological, physiological and

behavioral changes in the body. It is generated and manifested at the level of the nervous
system, which is fundamentally composed of cells called neurons. Neurons constitute the
elementary units for the transmission of information in the nervous system. Information within
the same cell travels from one end to the other using electrical impulses . But this electrical
impulse cannot pass directly from one neuron to the other, since there is a space between
them (the so-called synaptic space) and they do not touch each other. Communication from
one neuron to another occurs through neurotransmitters, which are chemical substances
released by neuronal terminals. These neurotransmitters, which to understand us are like
chemical keys, are released into the synaptic space (which separates one neuron from the next)
where they travel until they reach the receptors (let's say they are like chemical locks) of the
next neuron, causing changes in permeability. of its membrane, which generates an electrical
impulse or potential, which will travel throughout the cell, to the other end, and so on until it is
necessary.
Most of the psychopharmacological treatments currently used by psychiatry act
chemically on the neurotransmission systems, trying to conveniently regulate the activity of
certain areas of the nervous system involved in the disorder to be treated.
In the treatment of anxiety, two types of drugs are commonly used: anxiolytics and
antidepressants.
The most used anxiolytics belong to the group of high-potency benzodiazepines
(Alprazolam, Loracepam, Diazepam, Cloracepam, etc.). They produce an effect
17Source: Carlos De Lope (2007). Psychiatrist. Ansie Clinic in Barcelona and Madrid.
Anxiety disorders
CAMPUS
UNIVERSITY
soothing. They work by reducing anxiety symptoms in a matter of minutes and reducing both
the intensity and frequency of anxiety episodes. The main adverse effects of bezodiazepines
consist of drowsiness, memory disturbances, and disturbances in attention and concentration.
The deterioration of these cognitive functions is usually temporary (it is experienced while
taking the medication) and only occurs with high and prolonged doses over time. Another
drawback is that prolonged consumption can generate effects of dependency (addiction) and
tolerance (progressive loss of effectiveness).
The antidepressants commonly used today in the treatment of panic disorders are
SSRIs (Selective Serotonin Reuptake Inhibitors). They constitute the primary treatment of
choice. Various studies point to the involvement of serotonin as the main neurotransmitter
involved in Anxiety Disorders, although there are others. The group of SSRIs consists of
Fluoxetine, Paroxetine, Fluvoxamine, Sertraline, Citalopram and Escitalopram. They have a high
specificity against anxiety and few side effects (mainly weight gain, drowsiness, and sexual
dysfunction). They hardly have interactions with other medications and do not create
dependence. As drawbacks of SSRIs we will mention the side effects of the first days (nausea,
headaches, temporary increase in anxiety, etc.). For this reason, it is advisable to start
treatment with low doses, and combine tranquilizers for the first weeks. In some patients,
depending also on the drug chosen, they may cause some weight gain, or some loss of appetite
or sexual response. Normally, the doctor will inform the patient about the mild and transient
nature of these possible adverse symptoms. Another drawback is that the therapeutic effect
does not begin until 2-3 weeks after starting the antidepressant.
There is very often an initial reluctance to take psychopharmacological treatment,
based mainly on the patient's lack of knowledge regarding the medication and their fear of
becoming dependent on taking these medications, or that it will cause excessive sedation.
In many cases, after the therapeutic effect is achieved and the symptoms subside or
disappear, the patient already believes he or she is cured and sometimes abruptly and abruptly
abandons the medication. The professional must warn you of the risks inherent to this
Anxiety disorders
CAMPUS
UNIVERSITY
abrupt or premature suspension. Withdrawal of the medication must be scheduled by the

doctor at the appropriate time and gradually. Likewise, the professional must insist on correct
compliance with taking the drug as the only way to achieve the desired therapeutic effect. The
patient must also be informed about the possibility of other pharmacological alternatives other
than benzodiazepines and SSRIs in the event that a favorable clinical outcome is not achieved
with them. In the same way, the patient will be informed about the risks of self-medication.
As an adjunct to psychopharmacological treatment, a modification of possible habits
that could negatively influence the improvement of anxiety should be attempted (for example:
consumption of caffeine, alcohol, cannabis, etc.).
The psychotherapeutic approach to anxiety disorders
consists mainly of eliminating the fears that can give rise to the
somatic symptoms that the patient perceives, as well as
suppressing the erroneous interpretations of the different bodily
sensations, together with the cancellation of possible avoidance
behaviors regarding to anxiety-inducing stimuli.
There are numerous studies that demonstrate the advantages of combined treatments
(Psychopharmacological and Psychotherapeutic) for Anxiety Disorders. It seems that even in
certain cases the strategy of using combined treatments produces an immediate therapeutic
result superior to that obtained with a separate psychotherapeutic or psychopharmacological
approach. It has also been observed that in the long term, and on certain occasions that these
advantages appear to be minor or even disappear. The proper sequencing of pharmacotherapy
and cognitive-behavioral psychotherapy can offer very good results. Cognitive-behavioral
techniques can also help in the process of discontinuing medication, particularly in the case of
long periods of consumption of anxiolytics.
Anxiety disorders
CAMPUS
UNIVERSITY
BASIC RULES FOR THE PREVENTION OF

ANXIETY AND STRESS PROBLEMS 18
Anxiety and stress depend on multiple factors, both situational and

personal, therefore, there are many variables that we can influence to
prevent or reduce anxiety and stress. On a personal level and in a very
general way, yes
take into account both types of factors (situations and individuals), it is worth pointing out some
ortant variables that we can influence:
The diet:
5 It is advisable to eat healthy, avoiding foods that overload our body with heavy
digestion or other negative consequences in the short, medium or long term (obesity,
cholesterol, etc.).
> Use eating time as a time to rest and
break with our professional activities.
^ It is good to take advantage of food to have a social and family life.
^ Do not abuse alcohol with meals.
Rest:
5 Get enough sleep, around eight hours.
^ Take vacations and weekends as time for leisure and rest.
^ Promote social relationships as an alternative to work.
^ Leave work at the office (both papers and worries).
Antonio Cano Vindel. President of the SEAS (Spanish Society for the Study of Anxiety and Stress).
Anxiety disorders
CAMPUS
UNIVERSITY
3. Physical
Exercise: 5 Moderate practice of some sport or physical exercise helps us
relax.
^ Walk every day for at least thirty minutes.
^ Use physical exercise activities to ventilate ourselves

(nature) and ventilate our thoughts by chatting relaxedly
with family or friends.
4. Organization:
5 The organization of time and our activities, establishing schedules, is
essential to be able to rest, not be worried, not suffer continuous
shocks, important forgetfulness, etc.
> Do not be late for appointments, taking into account minor delays
usual to be on time.
^ Know how to select activities when we cannot do everything.
5. Problem Solving and Decision Making:

5 Don't let problems go by: face them in a more active or
passive way, but deciding what is best in each case.
^ Make decisions following a logical process: problem
statement, analysis of alternatives (pros and cons),
choosing the least bad one. Don't go back.
> Not continually analyzing the problem or the
Anxiety disorders
CAMPUS
UNIVERSITY
alternatives: this produces anxiety.
6. Interpretation of situations and problems:

5 The stress caused by a problem or situation depends on the consequences we foresee,
but sometimes we exaggerate the negative consequences (we overestimate the
probability of something bad happening, we make a catastrophic analysis of the
consequences, we make a negative interpretation of an ambiguous situation , we carry
out negative anticipations and begin to suffer from a
problem that does not exist, etc.).
^ If we are nervous: understand that it is natural, anxiety is as
natural as fear, joy or anger, and not worry even more
because we are activated or nervous.
^ Act naturally, do not avoid problems, do not be worried about what others may think of
us or our problem.
^ It is good to know that others do not perceive our anxiety symptoms with the same
intensity that we are experiencing them.
^ It is good to think that others also have anxiety and that when we notice their anxiety
we do not condemn them (why do we have to be harsher on ourselves than on
others?).
> Do not add accessory elements to the problem.
7. Attributions and Self-esteem:

^ If we have done something well, recognize our own authorship and
congratulate ourselves for it (it was not luck, but our effort and
our ability).
^ If we have done something wrong, do not throw things out,
recognize that we have acted wrong on this occasion, analyze our
mistakes and correct them, without blame, without negative
thoughts about ourselves ("this time I did it wrong, I must correct it") .
^ It is good to love each other and treat each other well.
Anxiety disorders
CAMPUS
UNIVERSITY
8. Relationships with others (partner, friends, colleagues, family, etc.):

5 Reinforce the positive behaviors of the people
around us, with approval, praise, smiles, small
details, etc.
^ Correct the negative behaviors of the people
around us, giving them information in time and
our disapproval, but without anger, blame, or
other punishments.
^ Do not continually bring up the problems of the past, the faults of others (and the
we forgive).
^ Always remember that a couple in crisis exchanges many punishments and few
reinforcements, just the opposite of a couple without problems.
9. Specific Training in Anxiety and Stress Control Techniques:

5 Practice Relaxation with some regularity in the moments
when we feel worse, dedicating some time to ourselves.
^ Read a good self-help book to learn to think well,
eliminating some erroneous thoughts, irrational ideas, etc.,
that stress us.
^ Expose ourselves little by little to the situations that we are
afraid of.
^ Learn to say no, when it costs us a lot, but we know that it is better to say no.
^ Practice our best social skills.
^ If we have difficulties, we do not know how to start these activities that can help us
control our stress, reduce our anxiety, and put ourselves in the hands of a good
specialist. If we follow their instructions, it will help us regain well-being and health.
Anxiety disorders
CAMPUS
UNIVERSITY
DSM-5. MODIFICATIONS REGARDING THE DSM-IV-TR
The modifications that appear in the fifth edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5) (American Psychiatric Association, 2013) for the diagnostic class of
anxiety disorders (AD), with respect to its previous edition can be considered in five major
headings:
1. The inclusion of two disorders that were previously found in the “Disorders with usual onset
in infancy, childhood or adolescence” section: separation disorder and selective mutism. The
latter is still reserved for early ages, while for separation anxiety it is recognized that the
disorder can occur in adulthood and have its onset after 18 years of age. The central aspects of
the diagnostic criteria remain the same although, for separation AD, it has been slightly
adapted for presentations in adulthood and not only in children and adolescents.
2. Although their close relationship with AD continues to be recognized, obsessive-compulsive

disorder and post-traumatic stress and acute stress disorders have ceased to belong to this
diagnostic class and are, the former, in a section of which it stands as the disorder central
(“Obsessive-compulsive and related disorders”) and the last ones in the chapter of “Disorders
related to stressors and traumatic events.
Anxiety disorders
CAMPUS
UNIVERSITY
3. Focusing on those that remain within the TA, the most relevant modifications are:
a) Panic attacks, although unchanged, are considered a specification potentially applicable to
any ED and also to many other disorders. Regarding the types of anxiety crises, two types have
been limited: expected and unexpected crises, replacing the three categories contemplated in
the previous version (situational, predisposed and non-situational).
b) Panic Disorder and Agoraphobia stand as independent diagnoses without any connection.
c) Both Agoraphobia and Specific Phobia and social anxiety disorder (called social phobia in the
previous version) have seen three modifications: 1. The need to recognize that the fear is
excessive or irrational is eliminated. 2. It is included that the clinician is the one who
determines whether the fear is excessive or irrational 3. The temporal criterion is added that
said alterations must have a minimum duration of 6 months.
d) In social anxiety disorder, the “generalized” specification is eliminated, replaced by “related
only to performance,” which should be indicated when the phobic fear is limited to speaking or
acting in public.
4. As with the rest of the DSM-V disorders, information on risk factors, prognosis, course and
evolution is included.
5. As in the rest of the DSM-V psychopathological disorders, a series of evaluation instruments

are included for the quantification of clinical manifestations. Specifically, three types of scales
have been included to quantify: a) the PROMIS, a 7-item questionnaire that measures
emotional distress b) different brief measures to measure severity and c) a global measure of
disability that assesses the patient's functioning in different areas of your life through 38 items:
WHO-DAS 2.0.
BIBLIOGRAPHY
Anxiety disorders
CAMPUS
UNIVERSITY
5 Mayor Lapiedra, M. T. (1991). Conduct Disorders in Childhood and Their Relationships to

Experiences of Anxiety and Depression. Zaragoza: University.
^ Arcas-Guijarro, S., & Cano-Vindel, A. (1999). Cognitive Processes in Generalized Anxiety
Disorder, according to the information processing paradigm. /Cognitive processes in
Generalized Anxiety Disorder by following the information processing paradigm.
Psicologia.com [Online], 3(1), 145 paragraphs. Available:
http://www.psiquiatria.com/psicologia/vol143num141/art_146.htm .
^ Arce, E. TO. (2000). The man of the 21st century: anxiety or plenitude? . Buenos Aires:
Editorial Argenta Sarlep.
^ Ayuso Gutiérrez, J. L. (1988). Distress Disorders. Barcelona: Martínez Roca.
^ Baeza Villarreal, J. c. (1995). Counterproductive spontaneous coping in Anxiety Disorders.
Bellaterra, Barcelona: Autonomous University of Barcelona.
^ Bobes García, J. (2001). Anxiety Disorders and Depressive Disorders in Primary Care.
Barcelona, etc.: Masson.
^ Bragado Álvarez, M. d. c. (1994). Behavior therapy in childhood: Anxiety Disorders. Madrid:
University-Business Foundation.
^ Horse, V. E., Carrobles, J. TO. I., & Buela Casal, G. (1995). Manual of psychopathology and
psychiatric disorders. vol.1, Conceptual foundations; anxiety, affective and psychotic
disorders . Madrid: Siglo XXI editors of Spain.
^ Cano-Vindel, A. (1989). Cognition, emotion, and personality: A study focused on anxiety. /
Cognition, emotion and personality: a study focused on anxiety. Madrid: Complutense
University.
^ Cano-Vindel, A. (2002). Cognitive techniques in stress control. In E. g. Fernández-Abascal &
M. Q. Jiménez Sánchez (Eds.), Stress Control (pp. 247-271). Madrid: UNED Editions.
^ Cano-Vindel, A. (2002). The anxiety. Keys to defeat it . Malaga: Arguval.
^ Cano-Vindel, A., & Espada Largo, F. J. (2003). Social Phobia and Simple Phobia: differences
and similarities in clinical manifestations. Anxiety and Stress , 9(1), 49-57.
^ Cano-Vindel, A., & Fernández-Castro, J. (1999). Cognitive Processes and Emotion.
(Monograph on 'Anxiety and Stress'). Murcia: Compobell.
Anxiety disorders
CAMPUS
UNIVERSITY
5 Cano-Vindel, A., & Miguel-Tobal, J. J. (1990). Differences between normal and psychosomatic
patients in the pattern of anxiety responses to different types of anxiety-inducing
situations . / Differences between healthy and psychosomatic subjects in the pattern of
anxiety responses in different types of situations. In COP (Ed.), Psychology and Health:
Health Psychology (pp. 62-67). Madrid: Official College of Psychologists (COP).
^ Cano-Vindel, A., & Miguel-Tobal, J. J. (1990). Evaluation through self-report of cognitive-
physiological-motor reactivity in different situations: Differences
individual and situational. / Assessment by self-report of the cognitive-physiological- motor
reactivity in different situations. In COP (Ed.), Diagnosis and Psychological Evaluation (pp.
94-101). Madrid: Official College of Psychologists (COP).
^ Cano-Vindel, A., & Miguel-Tobal, J. J. (2001). Emotion and Health. (Monograph on 'Anxiety
and Stress'). Murcia: Compobell.
^ Cano-Vindel, A., Pellejero, M., Ferrer, M. A., Iruarrizaga, I., & Zuazo, A. (2000). Cognitive,
emotional, genetic and differential aspects of shyness. / Cognitive, emotional, genetic and
differential facets of shyness. Electronic Magazine of Motivation and Emotion, 3(4),
extracted on June 30, 2000 from:
^ Carnwath, T and Miller, D. (1989). Behavioral Psychotherapy in Primary Care. Practical
Manual. Martínez Roca.
^ Casado Morales, M. I., Miguel Tobal, J. J., & Complutense University of Madrid. Faculty of
Psychology. Department of Basic Psychology II (Cognitive Processes. (2001). Anxiety, stress
and Psychophysiological Disorders [Electronic resource]. Madrid: Complutense University of
Madrid, Publications Service.
^ Derogatis, L. R., & Wise, T. N. (1996). Depressive and Anxiety Disorders in Primary Care.
Barcelona: Martinez Roca.
^ Echeburúa, E. (1993). Psychological Evaluation and Treatment of Anxiety Disorders. Madrid:
University-business Foundation.
^ Echeburúa, E. (1993). Anxiety disorders in childhood . Madrid: Pirámide Editions.
^ Echeburúa, E. (2002). Advances in the psychological treatment of Anxiety Disorders. Madrid:
Pyramid.
Anxiety disorders
CAMPUS
^ Echevurua
UNIVERSITYOdriozola, E. (2000). Anxiety disorders in childhood. Madrid: Pirámide Editions.
Anxiety disorders
CAMPUS
UNIVERSITY
5 Sword L, F. J., & Cano-Vindel, A. (1999). Anxiety Disorders and Depressive Disorder:
Differences in the manifestations of anxious and depressive symptoms . / Anxiety disorders
and depressive disorder: Differences in the manifestations of anxious and depressive
symptoms. Contemporary Psychology, 6(1), 30-35.
^ Espada, F. J., Torres, P., Cano-Vindel, A., & Ochoa, E. F. L. (1994). Evaluation of Anxiety
Disorders: Differentiation in the three response systems and situational areas. / Assessing
anxiety disorders: Three response systems and situational areas. Clinic and Health, 5(2),
209-217.
^ Eysenck, M.W. and Derakshan, N. (1997). A cognitive theoretical framework for Anxiety
Disorders. Anxiety and Stress , 3, 121-134 (Monograph 'Anxiety reduction techniques').
^ Fernández-Abascal, E. G., & Cano-Vindel, A. (1995). Cognitive activity. / Cognitive activity. In
E. g. Fernández-Abascal (Ed.), Manual of Motivation and Emotion (pp. 113-160). Madrid:
Ramón Areces Study Center.
^ Gil Andino, A., & Cano-Vindel, A. (2001). Application of Cognitive-Behavioral Techniques in a
case of Generalized Anxiety. Psicologia.com [On line], 5(3), Available at
www.psiquiatria.com/psicologia/revista/62/2255/?++interactive .
^ González-Ordi, H. (1997) (Ed.) Anxiety Reduction Techniques . Murcia: Compobell (Anxiety
and Stress, 3(2-3), pp. 115-358, monographic number).
^ Gutiérrez Calvo, M. (2000). Stress, anxiety and efficiency. Tenerife: Publications Service of
the University of La Laguna.
http://reme.uji.es/reme/numero2004/indexsp.html.
Ladouceur et al. (1994). Cognitive and Behavioral Therapy . Masson.
^ Lazarus, R.S. (2000). Stress and emotion. Management and implications on our health .
Bilbao: DDB.
^ Lazarus, R.S. and Folkman, S. (1986). Stress and cognitive processes . Barcelona: Martínez
Roca Editions. (V.O. 1984).
^ LeDoux, J.E. (1999). The emotional brain. Barcelona: Ariel/Planet.
^ Lobo, A., & Campos, R. (1997). Anxiety Disorders in Primary Care . Madrid: EMISA.
^ Marks, I. (1986). Treatment of Neuroses. Martínez Roca.
Anxiety disorders
CAMPUS
> McKay M. et al. (1985). Cognitive Techniques for Stress Control . Martínez Roca.
UNIVERSITY
Anxiety disorders
CAMPUS
UNIVERSITY
5 Mendez, FX and Maciá, D. (1994). Evaluation of anxiety problems. In R. Fernández-Ballesteros

(Dir.), Behavioral assessment today: an approach for change in clinical and health
psychology. Madrid: Pyramid.
^ Miguel Tobal, J.J. (1990). The anxiety. In J. Mayor and J.L. Pinillos (Eds.). Treatise on General
Psychology . (Vol.3). Motivation and Emotion. Madrid: Alhambra.
^ Miguel Tobal, J.J. (1995). Negative emotions I: Anxiety and Fear . In E.G. Fernández-Abascal
(Ed.). Motivation and Emotion Manual . Madrid: Ramón Areces Study Center.
^ Miguel Tobal, J.J. (1996). The anxiety. Madrid: Aguilar.
^ Miguel-Tobal, J. J., & Cano-Vindel, A. (1989). Advances in the evaluation of anxiety and its
implications in the choice of treatment. Behavioral Therapy. Giornale Italiano di Scienza e
Terapia del Comportamento, 22-23, 125-128.
^ Miguel-Tobal, J. J., & Cano-Vindel, A. (1990). Progress in the treatment of anxiety.
Adaptation of therapeutic techniques to individual characteristics. In COP (Ed.), Psychology
and Health: Health Psychology (pp. 270-274). Madrid: Official College of Psychologists
(COP).
^ Miguel-Tobal, J.J. (1995). Evaluation of Anxiety and Anxiety Disorders. In A. Roa (Ed.).
Evaluation in Clinical and Health Psychology. Madrid, CEPE, pp. 121-161.
^ Pérez-Nieto, M. A., & Cano-Vindel, A. (1998). Intervention in Social Phobia: Clinical Case.
Psicologia.com [On line], 2(2), Available in:
^ Peurifoy, R. Z. (1993). Conquer your fears: Anxiety, Phobias and Panic . Barcelona: Robin
Book.
^ Peurifoy, R. Z. (2000). How to overcome anxiety: a revolutionary program to eliminate it
permanently (2a. ed.). Bilbao: Desclée de Brouwer.
^ Quero, S. and Botella, C. (2012). Psychological Treatment of Post-Traumatic Stress Disorder.
Focad Document. Jaume I University.
^ Rivero, R. and Pastor, A. How to intervene step by step and session by session in Anxiety
Disorders. Publications Service of the Spanish Association of Clinical Cognitive Behavioral
Psychology (AEPCCC).
^ Rodríguez-Naranjo, C. (2000). From the principles of Psychology to Clinical Practice . Madrid:
Anxiety disorders
CAMPUS
Pyramid.
UNIVERSITY
Anxiety disorders
CAMPUS
UNIVERSITY
5 Ruiz, J.J. (1994). Fundamentals of Cognitive Psychotherapy. Request.

^ Sanz, J. (2000). Cognitive Processes in Anxiety and Depression . Madrid: Complutense
University of Madrid.
^ Silva, F. (1996). Some methodological issues in the evaluation of anxiety. Anxiety and Stress ,
2(2-3), 119-130.
^ Tobeña Pallarés, A. (1986). Anxiety Disorders: Origins and Treatment. Barcelona: Alamex.
^ Vallejo Ruiloba, J., & Gastó Ferrer, C. (1999). Affective Disorders, Anxiety and
Depression (2nd ed.). Barcelona [etc.]: Masson.
^ Varela, P. (2002). Anxiously. Keys to recognize and challenge anxiety . Madrid: The sphere of
books.
^ Vincent E. Caballo et al. (1996). Manual for the Cognitive-Behavioral Treatment of
Psychological Disorders. Volume I. Ed. XXI century.
www.psiquiatria.com/psicologia/vol2num2/art_7.htm .
^ Websites:
• http://www.psicologia-online.com/ebooks/general/trastornos-de-ansiedad.html
• diposit.ub.edu/dspace
• http://www.redsanar.org
• http://www.clinicadeansiedad.com
1
You can consult the Diagnostic Criteria (DSM-V and ICD-10) for Anxiety Disorders at the link included in the
Resource Guide.
Anxiety disorders

Anxiety Disorders

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Anxiety Disorders

Uploaded by

Copyright:

Available Formats

Master in Psychology

Anxiety disorders [4]

^ Generalized Anxiety Disorder…………………………………………………………. P. 19

Anxiety disorders [5]

Anxiety disorders [6]

Anxiety disorders [7]

Anxiety disorders [8]

Anxiety disorders [9]

Anxiety is at the root of many, if not all, of our

To understand what Anxiety Disorders are, you must first think

Cognitive activity is related to physiological activation. When cognitively evaluating the

• Panic Attacks or Anxiety Crisis.

• Posttraumatic Stress Disorder.

• Mood Disorders (Major Depression, Dysthymia, etc.).

• Addictions (Tobacco, Alcohol, Caffeine, Cannabis Derivatives, Cocaine, Heroin,

• Eating Disorders (Anorexia, Bulimia).

• Cardiovascular Disorders (Coronary Heart Disease, Hypertension, Arrhythmias,

• Disorders Digestive (Irritable Colon, Sore).

• And other Psychophysiological Disorders (Tension Headaches, Chronic Pain,

• Disorders related to the immune system : Cancer, Rheumatoid Arthritis, etc.

Chronic Pain, Terminal Illness, etc.

Positive emotional expressions facilitate communication, while negative emotional

• Avoidance of feared situations.

• DSM-V (American Psychiatric Association, APA)4 .

shaking, difficulty breathing, feeling of choking or suffocation,

DESCRIPTION OF ANXIETY DISORDERS

Panic Attacks and Panic Disorder

Example 1: Hello, my name is Silvia, I am 28 years old, and I live in Palma de

Example 2: Hello, good afternoon. I am a 26-year-old boy whose life has

Example 1: Approximately 4 months ago I started with general malaise,

The ancient term Agoraphobia translates from Greek as the fear of

Example: My name is Lola. I am 40 years old. I work as a technician in a

SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)

Example 1: Hello. My name is María, I am 34 years old and I am from

Example 2: I am a very shy person, I am 31 years old and I have a degree in

Social Phobia, also known as Social Anxiety Disorder, describes people

Generalized anxiety disorder

Generalized Anxiety Disorder is defined by a prolonged (duration > 6

Separation anxiety disorder and selective mutism

DESCRIPTION OF DISORDERS RELATED TO STRESSORS AND

Acute Stress Disorder refers to anxiety and behavioral disorders that

DESCRIPTION OF OBSESSIVE-COMPULSIVE DISORDERS

Example: Hello, my name is Santiago and I am 25 years old. I suffer from

Obsessions are recurrent, intrusive thoughts, impulses, or images

We could also include Hypochondria here (even though it is

There are three other disorders related to Obsessive-Compulsive Disorder5

This may be 1 to 3% of the population, and two-thirds are men.

Agoraphobia ^ Procedures for exposure to avoided or

Social phobia ^ Procedures of Restructuring

Obsessive-Compulsive Disorder ^ Procedures for exposure to underlying fears

Stress Disorder ^ Procedures of exposure to

TREATMENT OF ANXIETY DISORDERS6

Although in Anxiety Disorders there are

Patient with signs /

Consider ADAPTATION disorder \

Mental disorder due to

ALCOHOL DRUG use

Consider another mental

PRIMARY ANXIETY DISORDERS

PANIC DISORDER (PANIC DISORDER)

1. DIAGNOSTIC GUIDELINES FOR DSM-V PANIC DISORDER

catastrophic automatics); those interpretations sensations (thoughts