Chapter 7: Behavorial Methods II

Reducing Anxiety and Breaking

Patterns of Avoidance
Mehak Chopra

Behavorial Analysis of Anxiety

Disorders

Report intense subjective experiences of fear with physical symptoms of

arousal when exposed to a threatening stimulus
Ex.

Man climbing up a tall ladder

Feared object (stimulus) & reaction of anxiety (response)

UCS

(unconditioned stimulus) UCR (unconditioned response)

Stimulus generation: triggering of anxiety by associated reminders

Reminders:
CS

conditioned response (CR)

CR

Anxiety disorders arise from people trying to avoid experiencing situations

that will adverse emotional & physiological responses

Behaviors

People will avoid going to places b/c it provides emotional relief

Avoidance
Example

reinforces feeling of relief from anxiety

of Gina

Agoraphobia
Fear

of elevators

Therapy

related panic attacks

worked on using elevators again

OCD
Obsessional

thoughts occurs in people with OCD

Compulsive

rituals used to stop the thoughts

Key features

1. an initial (unconditioned) stimulus causes a fearful

(unconditioned) response and is generalized to
conditioned stimuli that in turn produce conditioned
response

2. pattern of avoidance of the feared stimuli serves to

reinforce the patients belief that he cannot face the
object/cope with the situation

3. pattern of avoidance must be broken for the patient

to overcome the anxiety

Studies

Automatic thoughts are irrational/illogical

Exaggerated

Fearful conditioned shaped by life experiences

Parents

or other influential people

Anxiety disorders cannot be traced back to single

stimuli

Overview of Behavorial Treatment Methods

Link between

1) stimulus (CS/ UCS) & 2) fear response (CR/UCR)

Avoidance must be replaced with a more adaptive behavior

Breaking the Stimulus-Response Connection

Reciprocal inhibition/exposure
Process

of reducing emotional arousal by helping the patient experience a positive or healthy emotion that counteracts a
dysphoric response
Induce deep relaxation of voluntary musculature state of calm which is incompatible with intense
anxiety/arousal

Example:

Practice
Example:

method regularly

exposure

Repeated

exposure allows person to realize that the stimulus can be faced and managed

Physiological
Cognitive

response cannot be sustained

restructuring techniques

Methods

that reduce/turn off negative thoughts can lower tension levels

Replace

fearful cognitions with more pleasant/calming thoughts (ex. relaxing mental images)

Decatastrophizing

helps the patient

1)

systemically evaluate the likelihood of an imagine catastrophic outcome occurring on exposure to the stimulus

2)

develop a plan to reduce the probability that such an outcome will occur

3)

create a strategy to cope with the catastrophe

Sequencing Behavorial Interventions for

Anxiety Symptoms

First:
Assess

symptoms (anxiety triggers, existing coping strategies)

Define

course of therapy

Second:
Taught

basic skills for coping with

thoughts/feelings/behaviors

Third:
Use

skills to assist patients in exposing themselves to anxiety

provoking situations

Step 1: Assessment of Symptoms,

Triggers, Coping Strategies
Delineate
1.

Events (memories of events/streams of cognition) that serve as trigger

2.

Automatic thoughts, cognitive errors, underlying schemas involved in the overreaction to the feared stimulus

3.

emotional and physiological responses

4.

habitual behaviors such as panic/avoidance symptoms

Scales

used: BECK, Fear of Negative Evaluation Scale, State-Trait Anxiety Inventory, Yale-Brown Obsessive
Compulsive Scale

Methods
Identification
Use

of places/situations/people that illicit anxiety

a scale from 0-100 (100 most extreme)

Baseline
Positive

assessments/measuring progress

reinforcement:

Positive

consequence follows a behavior

Behavior
Careful

will occur again

of family members that may facilitate avoiding as a coping strategy

Step 2: Identifying Targets for

Intervention

Therapist and patient decide to

Begin

by attacking the most difficult situation or ease

the patient into exposure therapy in a step-by-step
fashion

Step 3: Basic Skills Training

Five methods described

1. Relaxation Training

Achieve relaxation response

Muscle relaxation

Mental and physical calmness

Seen in table 7-1

Explain rationale for relaxation training

Teach patients to rate their level of muscle tension and anxiety

Explore the range of muscle tension

Teach the patient methods for reducing muscle tension

Help the patient systematically relax each of the major muscle groups of the body

Suggest mental images that may assist in relaxation

Ask the patient to practice the relaxation induction method regularly

Listen to an audiotape/read

2. Thought Stopping

Stop the process of negative thinking and replace it with more positive/adaptive thoughts

May or may not be useful

OCD may worsen (intensification of obsessions)

Methods:

Recognize that a dysfunctional thought process is active

Give a self-command to stop the thought

Stop!

Quit thinking that way!

Evoke a visual image to reinforce the command

Stop sign /red traffic light/ gloved hand

Switch the image

From stop sign to a pleasant/relaxing scene

Vacation spot, pleasant person, photograph

Ask patient how the experience was and feedback regarding the session

Distraction

Breathing retraining

Using images to help the patient generate positive, calming scenes that
can be used to relax

Reading, going to a movie, working on a hobby/craft project,

socializing with friends, spending time on the Internet

Effective distraction facilitates participating in exposure and other

behavorial interventions by reducing the frequency/intensity of
automatic thoughts & lowering physical tension and emotional distress

Decatastrophizing

Refers to Video 2

1. Estimate the likelihood that the catastrophic outcome will occur by asking patients to rate their belief on a scale
from 0 to 100% (absolute)

2. Evalute the evidence for and against the likelihood that a catastrophic event will occur

Fears vs facts

3. Review the evidence list and ask patients to re-estimate the likelihood of the catastrophe occurring

Should have reduced from step 1

4. Assess perceived control by asking patients to rate the extent to which they believe they have control over the
occurrence of the event /outcome

5. Create an action plan

6. Develop a plan for coping

If the event should occur

7. Reassess the perceived likelihood of the catastrophic outcome

Strategies that will reduce the likelihood that the catastrophe will occur

As well as the degree of control over the outcome

8. Debrief

Ask what it was to talk about the catastrophic event

Breathing Retraining

Often used in treatment of panic attack/disorder

Breath

rapidly and deeply for a short time (max of

1.5 mins)

Breath

slowly until regaining normal control over his

respiration

Step 4: Exposure

Some situations/phobias can be treated in a single session

Flooding

therapy (directly face the stimulus while the therapist models coping with
the situation)

Systematic desensitization
Step

by at step protocol

Developing a Hierarchy for Graded Exposure

Be

specific

Rate

the steps for degree of difficulty or amount of expected anxiety (scale 0-100)

Develop

a hierarchy that has multiple steps of varying degrees of difficulty

Range
Choose

of difficulty (low to high)

steps collaboratively

Work

as a team with the patient to select the order of the steps

Imaginal Exposure vs In-vivo Exposure

Imaginal
1)

use environmental cues to create vivid imagines of the feared stimuli

2)

use cognitive restructuring, relaxation, thought stopping, or other

CBT methods to decrease anxiety and dispel the negative imagine

3)

present the images in a hierarchical fashion (take the lead in choosing

specific targets)

4)

coach the patient on ways to cope with the anxiety

5)

repeat the imaginal exposure until anxiety is extinguished

In Vivo Exposure

Direct confrontation with the stimulus that arouses fear in

the patient

Presence of therapist positive b/c

Model

effective anxiety management techniques

Encourage
Provide
Modify
Give

patient to confront their fears

timely psychoeducation

catastrophic cognitions

constructive feedback

Response Prevention

Methods used to help patients stop behaviors that are perpetuating their
disorder

Therapist and patient work on specific goals for response response

prevention
Patient

keeps a log

Rewards

Positive reinforcement by friends/family/therapist

Going

out to eat

Trips

Pacing Exposure Therapy

Ranges from single visits (simple phobias) to lengthy protocols

Keep in mind patients diagnosis, comorbid conditions, strengths,

intelligence, resilience, motivation, readiness for change, patients
response to therapy