Blog

A therapists thoughts for the day and special articles on CBT and improvement

Anxiety Individual Treatment Self-improvement Therapy May 14, 2017 By grantcryan 0 Comments

The following is an example of an anxiety issue Social Phobia or Social Anxiety : A fictional case study

Fictional Case Study

Demographic Data

Client Description

A 45-year old Male, his family has no particular religious affiliation but he believes he has Christian based values and is more inclined than not to believe there is a creator.

Relationship Status

Married and reports that his marriage is very stable and his wife is understanding and supportive; the family dynamic is egalitarian. They have two children.

Occupation

Client is self-employed in the business of marketing. His business is maintaining, but he has concerns the future.

Parents / Siblings

Clients mother is deceased; father is still alive. He has one younger male sibling. Client stated that he was never close to his brother, and has very little contact with both him and his father. The client has no contact with other extended family in NZ.

Treatment History

Client has had previously seen by a psychiatrist who suggested a diagnosis of a Major Depressive episode with associated features of anxiety, the client was prescribed medication. Both the client and his GP decided an appropriate adjunct to the medication would be talk therapy.

Presenting Problems

Problem:

Client said he has self-doubt and a growing lack of confidence in work and social situations when trying to develop relationships. In business and social interactions, he becomes anxious and believes he is unlikable and not good enough. Client believes people will notice his anxiety and lack of confidence, and think he is incompetent, defective or weird.

The client stated that he continuously worries about failing and how catastrophic his future will become. Client is less active and has reduced social contact with his friends.

Cross-sectional details:

Situation: Socialising with friends and acquaintances.
Thoughts, Beliefs: They think I am boring, I have nothing interesting to say, they don’t really like, I sound stupid
Feelings: Depression, Anxiety
Biology: (sensations) Tension, breathing rate increases, upset stomach.
Behaviour: Reduce eye contact, go quiet and withdraw, drink more to reduce the anxiety, leave early.

Situation: Presenting my products at a conference of 50 people.
Thoughts: I can’t do this, I’m a failure, I’m not good enough to present to these professionals, they can see I’m anxious and lacking confidence, this is terrible, I am so ashamed.
Emotions: Depression, anxiety
Biology: Racing heart, flushed face, dry mouth, racing thoughts.
Behaviour: Focus on notes, focus sensation, speak fast, and plan on ways to shorten the presentation, look for ways to escape.

Brief Historical Context of the Clients Problem

Client said he has believed for most of his life he is not good enough and less worthwhile than others.

He stated that during his young adult years he was shy and remembers feeling sad and anxious a great deal of the time; he didn’t have many friends. Client said this was mainly due to believing that he was fundamentally flawed, different from others and didn’t fit.

Over the past twenty years he had worked for a variety of companies with varying success. He said he mainly worked behind the scenes where there was less pressure to perform and less risk of failure.

Client reported that although he has a low opinion of himself, he has friends who like him, and have shown concern for his wellbeing. He said he has strengths that he is reluctant to acknowledge; he is polite and personable, has a good sense of humor, and in spite of his belief, he has good social skills.

Early Developmental Life History

Client described his father as being highly critical, unaffectionate and distant. He said his father was prone to mood swings and was often angry and unpredictable. Client said he felt very anxious around his father and would avoid being in his presence. He said his father told him to never get above his station or that he would never amount to much. He said he believed his father did not love or care for him.

Client said his mother was a frail vulnerable person who was loving and tried to be happy. He believed that she loved him and would always be there for support.

Client said his parents seemed indifferent towards each other and has no memory of them showing affection to one another. Although his father was not physically violent Client said he constantly intimidated the family verbally with critical angry outbursts about not behaving the way he thought he should.

Clients mother became unwell and died of cancer when he was in his late teens. The gap between his father, his brother and himself grew to the point where hardly a word was spoken and as soon as possible client moved out of the family home.

Clients Goals for Therapy

Reduce symptoms of depression and anxiety.
To increase pleasurable activities both individually and socially.
To decrease procrastination and avoidance of work issues. To decrease anxiety and increase confidence when socialising and making important work related presentations to prospective clients.
To develop self-acceptance, self-positive regard and change absolute beliefs such as Failure, Defectiveness & Shame and Unrelenting Standards (the need for perfect performance).
Reduce the need for approval.
Learning to be more assertive

A diagnostic assessment, and outline of a Conceptualisation.

The diagnosis and conceptualisation are based on clients self reporting and objective measures: Questionnaires: Multimodal Life History Questionnaire, Dysfunctional Attitude Scale, Fear of Negative Evaluation Scale, Depression and Anxiety Inventories and the DSM-IV-TR. DSM IV: Diagnosis: Major depressive disorder – recurrent, with a co-morbidity of Social anxiety with associated features of GAD

Conceptualisation

ELH

Father: Rejecting, Critical, uncaring and Threatening

Mother: Vulnerable, fragile, loving and unwell. Died at a relatively young age, when Client was in his late teens.

Development of Schema (core beliefs)

Self: I am a failure. I am worthless, defective and incompetent. Vulnerable to harm

I must have approval from others to be of value

Others: Others expect me to be perfect and will condemn me when I am not.

World: My world is overwhelming and is a dangerous place

Future: The future is bleak and terribly unpredictable, things will never get

better, feeling hopeless

Assumptions & Rules

If I can get others approval, then I am safe and a good person of value

I must always perform perfectly

I must always be confident

I should never be anxious or show vulnerability.

Precipitating Events

Dealing with clients when the running his business and

Social situations, or public speaking

Negative beliefs

I wont be able to cope, I will be overwhelmed by my anxiety

I am not competent enough to succeed

I am a failure

Symptoms of depression and anxiety

Thoughts, Emotions, Physical symptoms, Behaviour

Interacting in a vicious cycle

Therapy September 20, 2016 By grantcryan 0 Comments

GAD

Of all the anxiety issues Generalised Anxiety Disorder (GAD) is considered to be the most prevalent, and some investigators have argued that GAD may be the most difficult of the anxiety disorders to treat. Generalised Anxiety Disorder was first introduced as a diagnosis in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (APA, 1980). Although there are other cognitive and somatic symptoms, it was not until the publication of DSM-III-R (APA, 1987) that GAD was uniquely defined by chronic and pervasive worry (Barlow, Blanchard, Vermilyea, Vermilyea & DiNardo, 1986), causing significant impairment across most of the domains of a persons life.

The diagnostic criteria for GAD In the Diagnostic and Statistical Manual of Mental Disorders has changed very little over the years. it was revised in the DSM-IV-TR and the only difference between this and the most recent manual the DSM-V is the change from 6 months of worry occurring to 3 months as one of the diagnostic conditions (APA 2013). It has been suggested that the classification should be re-labeled Generalised Worry Disorder

A reductionistic view of the DSM diagnostic criteria for GAD are, excessive anxiety and worry (apprehensive expectation), about a number of events or activities. The person finds it difficult to control the worry. The anxiety and worry are associated with restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension and sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep).

The prevalence of GAD is quite remarkable and it is considered to be the most reported of all the anxiety disorders. In a recent survey by the National Institute of Mental Health in America it showed that GAD affected about 6.8 million Americans 18 years and older in a given year. In a New Zealand survey published by the Mental Health Foundation of New Zealand 1997, it was suggested that Generalised Anxiety Disorder affects almost one-third of the adult population during their lifetime.

It seems that GAD can develop gradually, and begin at any point of our lives. Patients with GAD often present with a life-long history of generalized anxiety. Several studies have found that a large proportion of patients with GAD cannot report a clear age of onset or report an onset dating back to childhood (see, e.g., Anderson, Noyes, & Crowe, 1984; Barlow, Blanchard, Vermilyea, Vermilyea, & Di Nardo, 1986; Butler, Fennell, Robson, & Gelder, 1991; Cameron, Thyer, Nesse, & Curtis, 1986; Noyes, Clarkson, Crowe, Yates, & McChesney, 1987; Noyes et al., 1992; Rapee, 1985; Sanderson & Barlow, 1990).

Therapy Help • Youngsters February 23, 2015 By grantcryan 0 Comments

The nature of worry

Several authors have confirmed that all people worry, and often do so as a part of a problem solving process, so worry can be considered a useful strategy. A distinguishing feature of chronic worriers is that when worrying they have difficulty remaining problem solving oriented; they have a tendency to become catastrophe oriented, a part of that process includes the expectation that their worst fears about a anticipated event or one that has already taken place, will come true. Chronic worries seem to perceive themselves as predominately unsafe in this world until proven otherwise; non chronic worriers on the other hand seem to perceive themselves as the antithesis of this view, and as being safe until proven otherwise.

Relatively speaking it was only recently that effective psychological treatments for this problem have been developed and that enough evidence has been collected to show that GAD can be treated successfully.

Most of the early interventions for GAD were based on similar approaches to phobic disorders and used exposure strategies, such as systematic desensitisation as well as relaxation training. The nature of GAD was too broad for such seemingly less developed treatments.

The following treatment approaches are far more robust and have shown to be more effective with the treatment of GAD. In saying that, some of the exposure strategies and relaxation training are still applicable, but are augmented by more thoroughly researched techniques, and a greater understanding of GAD.

Therapy Business • Work February 23, 2015 By grantcryan 0 Comments

Cognitive Behaviour Therapy

Based on the research there seems to be a general consensus that CBT is an effective approach for the psychological treatment of GAD. It has been the most researched and is considered to be the most widely used as an initial approach, (Borkovec, Newman & Castonguay, 2003), (Erickson & Newman, 2005)

According to Durham and Fisher (2007), (up to that time) there had been 30 clinical trials based on DSM diagnostic criteria, the main focus of which was CBT. Newman, (2000), reported that from this research the outcome showed that only 50% of clients with GAD experienced a reduction in symptoms, when compared to non-diagnosed individuals.

The first research trials to asses the effectiveness of CBT for the treatment of GAD included early studies from (Barlow et al., 1984; Barlow, Rapee & Brown, 1992; Blowers, Cobb & Mathews, 1987; Butler, Cullington, Hibbert, Klimes & Gelder, 1987; Lindsay, McLaughlin, Hood, Espie & Gamsu, 1987) and combined relaxation therapy (RT), Anxiety management packages, with a mixture of cognitive therapy (CT) behaviour therapy (BT) and cognitive behaviour therapy.

The studies demonstrated greater improvement compared to a non-directive approach. Two studies by Borkovec et al., (1987, and Butler, Fennell, Robson & Gelder (1991), concluded that CBT was more effective than BT. Chambers and Gillis (1993) in a seven-study meta-analysis reported that CBT was substantially more effective than a wait list or placebo.

A study by Dugas et al., (2003) produced the following outcomes. Treatment was applied to group cognitive behaviour therapy. There were 5-6 groups with 4-6 participants with a total of 52 clients diagnosed with GAD. The treatment was for 14 weekly 2-hour sessions managed by two clinical psychologists. The percentage of clients who no longer met the criteria for GAD were 60% at post, 88% at 6 months, 83%, at 12 months and increased to 95% at a 2 year follow up.

In summary, researchers have confirmed that CBT is an effective and valid treatment approach for reducing pathological worry and somatic symptoms of GAD. In saying this there is still a percentage of clients with GAD who do not seem to benefit from what may be considered the most effective treatment.

In the next part of the review I will explore other possibilities for psychosocial treatments for GAD that attempt to stand alone or are combined with CBT.