April 13, 2012

Three Essential
Pieces for Solving
the Anxiety Puzzle

Simon A Rego, PsyD, ABPP, ACT

Michelle A Blackmore, PhD
Montefiore Medical Center
Albert Einstein College of Medicine
 Agenda
O Cognitive-behavioral theory: A quick
review
O Where’s the beef? A summary of the
literature
O My cherry pie: 3 essential ingredients
O Bonuses:
O A quick note on:
1) Combining CBT w/ medications
2) “Third Wave” therapies
 In Brief, CBT:
O Is based on a model of the emotional
disorders which emphasizes the integration
of thoughts, feelings, and behaviors.
O Utilizes the bi-directional relationship between
thoughts, feelings, and behaviors to help
patients decrease negative affective states
and attain a better quality of life.
 The CBT Triangle
Feelings of anxiety

T
Role play!

B C
Escape, avoid or cope “This is threatening!”
 Principles of CBT
O Brief and time-limited
 Principles of CBT
O Focus is on the “here and now”
 Principles of CBT
O Relies on “active collaboration” b/w the patient
& therapist (“collaborative empiricism”)
 Principles of CBT
O Sessions are structured
O Treatment is skills-based
O Therapists are directive
O Homework is a key element
O Relapse prevention is built into the
treatment
O The end goal is to have the patient
become his/her own “therapist”
 Where’s the Beef? A
Summary of the Literature
O CBT “works” for the anxiety disorders!!!
O A Guide to Treatments That Work (Nathan & Gorman,
2007)
O Effective Treatments for PTSD: Practice Guidelines from
the ISTSS, 2nd Edition (Foa, Keane, Friedman, & Cohen,
2008)
O A Meta-Analytic Review of Adult Cognitive-Behavioral
Treatment Outcome Across the Anxiety Disorders (Norton
& Price, 2007)
O The Empirical Status of Cognitive-Behavioral Therapy: A
Review of Meta-analyses (Butler, Chapman, Foreman, &
Beck, 2006)
Generalized Anxiety Disorder

O “The most successful psychosocial

treatments combine relaxation exercises
and cognitive behavior therapy in an effort
to bring the worry process under the
patient’s control.”
O Treatments integrating emotion regulation
& mindfulness components also show
effectiveness
Obsessive-compulsive Disorder

O “Cognitive behavioral therapy involving

exposure and ritual prevention methods,
which reduce or eliminate the obsessions
and…rituals of this disorder, is the (other)
first-line treatment for OCD.”
 Panic Disorder
O “Cognitive behavioral treatments that
focused on education about the nature of
anxiety and panic, and provided some
form of exposure and coping skills
acquisition have proven efficacious.” (in
PD)
O “Situational in vivo exposure
substantially reduced symptoms.” (in
PDA)
Social Anxiety Disorder
O “Exposure-based procedures and…
cognitive behavioral treatments most
effectively reduced or eliminated the
symptoms of social phobia.”
O “Social skills training and relaxation
techniques have also been used with
some success.”
 Specific Phobias
O “Exposure-based procedures, especially
in vivo exposure, reduce or eliminate
most or all components of specific phobic
disorders”
O “No pharmacological intervention has
been shown to be effective for specific
phobias”
Posttraumatic Stress Disorder

O “Evidence from many well controlled

trials with a variety of trauma survivors
indicates that exposure is efficacious.”
O Cognitive processing of traumatic event
shown to be important component of
treatment
 Intent-to-treat Sample: the Lines of Best Fit,
Mathematical Functions, and Explained Variances for
the Mean Total PSS Scores for Prolonged Exposure and
Cognitive-processing Therapy.

N=171

Nishith et al., (2002). Pattern of change in PE and CPT for female rape victims with PTSD. JCCP, 70(4), 880-886
Total CAPS Scores in CPT, PE and MA-CPT and MA-PE
Conditions: Treatment Completers

N=121

p<.0001

Resick et al., (2002). A comparison of CPT with PE and a Waiting Condition for the treatment of
chronic PTSD in female rape victims. JCCP, 70(4), 867-879.
Percentage of Participants No Longer Meeting DSM-IV-
TR Criteria for PTSD After Treatment

N=60

Taylor et al., (2003). Comparative Efficacy, Speed, and Adverse Effects of Three PTSD
Treatments: Exposure Therapy, EMDR, and Relaxation Training. JCCP, 71(2), 330–338
 My Cherry Pie: 3 Essential
Ingredients in CBT for Anxiety

O Exposure to anxiety-provoking
triggers while blocking/eliminating
“safety behaviors”
O Enhance anxiety management skills
O Restructure faulty and/or
maladaptive cognitive processes
 Strategy 1a: Exposure to
Anxiety-provoking Triggers
O Goal: diminish or extinguish anxiety
associated with patient’s trigger stimuli
O How: via systematic, hierarchical, and
prolonged exposure to anxiety provoking
stimuli without employing any anxiety-
reduction methods
O Why: a decrease in anxiety leads to
decreased urges to escape/avoid,
development of more adaptive behavioral
responses, and restructures faulty beliefs.
Exposure: Three Main Types

O In vivo
O Interoceptive
O Imaginal
Exposure: How Do You Do It?

O Provide subjects with a rationale

O Develop a “SUDS” scale
O May also utilize Avoidance Scale
O Create a hierarchy
Exposure Should Always Be:
O Graded
O Gradual
O Prolonged
O Structured
O Repeated
O Assigned for homework
 Strategy 1b: Block or
Eliminate “Safety Behaviors”
O SBs: “actions that may fall short of outright
avoidance but still perpetuate the anxiety
reaction”
O Goal: design interventions that help the
patient understand these behaviors are
maladaptive
O How: via safety behavior experiments, self-
monitoring, psychoeducation, etc.
Strategy 2: Enhance Anxiety
Management Skills*
O Provide psychoeducation on the role of
anxiety
O Identify current anxiety triggers
O Assess current coping strategies
O Teach somatic/relaxation skills
O Progressive muscle relaxation
O Passive muscle relaxation
O Diaphragmatic breathing
O Transport to increasingly difficult situations
O Enhance with imagery, mindfulness, etc.
 Strategy 3: Restructure
Faulty Cognitive Processes
O Provide psychoeducation
O Information about the disorder!
O Provide rationale for the maintenance of the
symptoms
O Develop an idiosyncratic model
O Provide rationale for treatment interventions
O Discuss relapse prevention
 Strategy 3: Restructure
Faulty Cognitive Processes
O Include Self-monitoring & Self-Report
Assessments
O Self-monitoring:
O Allows patients to take an active role in treatment
O Increases awareness
O Establishes baselines
O Decreases maladaptive behaviors
O Self-report assessments
O Allows for objective, structured measurement of
symptoms
O Normalizes symptoms
O Allows comparisons to be made with established norms
 Strategy 3: Restructure
Faulty Cognitive Processes
O Engage in Formal Cognitive Restructuring
O Train patients to:
O Think flexibly
O Be a “scientist” with their symptoms
O Consider their thoughts and beliefs as
hypotheses rather than facts
O Pay attention to all available information
O Revise hypotheses according to incoming
information
Cognitive Restructuring
O Is not simply telling patients to think
positively!
Cognitive Restructuring: Basics

O Identify distortions
O Examine evidence for and against belief
O Conduct experiments to test belief
O Encourage thinking in “shades of gray”
O Conduct a survey
O Define negative terms and substitute less
emotionally loaded words
O Re-attribution theory
O Conduct a “cost-benefit” analysis of
maintaining belief
Common Distortion in Patients
w/ Anxiety: “Catastrophizing”
O See potential (social) consequences as
catastrophic and/or intolerable
O Challenge by:
O Imaging the worst
O Critically evaluating it
O How bad is it? Would you be able to cope
anyway?
O Is it a horror or a hassle?
O Have you experienced something like that
before?
Common Distortion in Patients
w/ Anxiety: “Overestimating”
O Thinking an improbable event is likely to
happen in the near future
O Challenge by:
O Evaluate evidence for and against
O How many times have I had that thought?
O How many times has _____ happened?
O How many times has _____ not happened?
O How likely is it to happen the next time I
think of it?
O Generate alternatives
Combining CBT & Medications
Proponents (“it seems logical…”)
 Adding medication to CBT will enhance
the outcome by reducing the patient’s
anxiety, thereby promoting his or her
ability to tolerate longer exposure(s) to
feared situations
 Evidence suggests that longer exposure is
more effective
Combining CBT & Medications
Opponents:
The reduction of anxiety caused by
medication will block the fear activation
that is a necessary condition for cognitive
changes that mediate treatment success
There now appears to be a negative
indication in combining CBT and
medications in patients with panic
disorder
A Closer Look at the Literature

O Number of RCTs comparing CBT to

medications or examining the
combination of these approaches for
treating anxiety disorders?
O 26!!!
CBT With & Without Meds
in Anxiety Disorders
O Foa, Franklin, & Moser (2002) conducted a
comprehensive literature search of
published randomized trials comparing
treatment with CBT or medications
O Reviewed in detail 10 studies meeting their
inclusion criteria (e.g., established
diagnosis, at least 2 treatment groups,
adequate methodology, etc.)
 Foa, Franklin, & Moser
(2002): Results
O For OCD, SAD, and GAD: at post-treatment
and follow-up, there was no demonstrable
advantage or disadvantage of combined
treatment over CBT alone
O In the few studies that allowed for such a
direct comparison, there appears to be some
advantage of combined treatment over
medications alone, suggesting that a course
of CBT should be considered for patients
receiving medications alone – especially
partial responders
 Foa, Franklin, & Moser
(2002): Results (Cont.)
O In contrast to results for OCD, SAD, and
GAD, combined treatment for PD seems to
provide an advantage over CBT alone at
post-treatment
O However, adding medications to CBT in PD
appears to be associated with a greater
relapse rate after treatment discontinuation
 Conclusions
O “The hope that combined treatments will
be a panacea for patients with anxiety
disorders has not been fulfilled”
O On the other hand, the worry that
combining treatments will negatively
impact treatment has not been realized
(except maybe for PD)
Acceptance and Mindfulness-
Based Behavior Therapies
(The “Third Wave”)

O Acceptance and mindfulness-based

therapies
O To name a few:
O Acceptance and Commitment Therapy (ACT)
O Mindfulness-based Cognitive Therapy (MBCT)
O Dialectical Behavior Therapy (DBT)
O Behavioral Activation (BA)
Acceptance and Mindfulness-
Based Behavior Therapies
O Focuses on strategies for changing the process &
function of cognitions rather than the content
O Ex: cognitive diffusion vs cognitive restructuring
O Targets experiential avoidance and encourages
experiential acceptance
O Ex: mindfulness increases present-focus, and
decreases over-engagement (e.g., rumination) and
under-engagement (e.g., avoidance)
O Focuses on value-directed goals and
improvement in quality, meaningfulness of life
Acceptance and Mindfulness-
Based Behavior Therapies

O Although well-controlled studies on acceptance

and mindfulness-based interventions for anxiety
disorders are limited, they are gaining empirical
support (Block, 2002; Forman et al., 2007; Hayes
et al. 2006; Roemer & Orsillo, 2008; Twohig et
al., 2007)
O It is unclear if these interventions have an
additive effect on outcome when included in
enriched CBT approaches for anxiety, although
the research look promising!
 “TBL”
O CBT “works” for anxiety disorders!
O CBT capitalizes on a “bi-directional”
relationship between thoughts,
feelings, and behaviors
O Include 3 main ingredients and the
treatment should go well!
 “THM”
O 3 Essential Ingredients in CBT for Anxiety
O Exposure to anxiety-provoking triggers
while blocking/eliminating “safety
behaviors”
O Enhance anxiety management skills
O Restructure faulty and/or maladaptive
cognitive processes
Questions???
Simon A. Rego, PsyD,
ABPP, ACT
718-920-5024
[email protected]

Michelle A Blackmore, PhD

718-653-4859, ext 225
[email protected]