ANXIETY can be a crippling experience. In essence, it is our body's response to conceivable future fear, and part of our survival instinct. Let's imagine a cave ...
COMMON FACTS ABOUT CBT • CBT is often used as a short-term treatment option. Sessions are usually concluded in 6-10 weeks. • CBT is an empirical approach. All the techniques are well documented and researched.
UNIVERSITY OF BOLTON - DENIZ UYANIK
CONCLUSION Generalized Anxiety disorder is a formidable foe because it can distract daily activities. You can get better with the help of Cognitive Behavior Therapy. By reading this informative booklet, healing process already started because you know that; • • • • • •
You are not the only one There is a treatment The way you feel is part of the biological survival process Anxiety happens because you have exaggerated negative automatic thoughts or worries It is possible to learn new and healthier behaviors The environment and other people have an effect on your cognitive process.
• CBT can be used to treat a wide range of problems such as depression, anxiety, chronic pain, sleep problems and more. • CBT helps you equip tools or techniques to deal with future problems.
REFERENCES American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. Washington DC: American Psychiatric Publishing. Barrouillet, P. (2015). Theories of cognitive development: From Piaget to today. Developmental Review, 38, 1–12. https://doi.org/10.1016/j.dr.2015.07.004 Bandura, A. (1989). Social Cognitive Theory. Annals of Child Development, 6, 1–60. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive Therapy of Depression. New York: THE GUILFORD PRESS. Chisholm, D., Sweeny, K., Sheehan, P., Rasmussen, B., Smit, F., Cuijpers, P., & Saxena, S. (2016). Scaling-up treatment of depression and anxiety: a global return on investment analysis. The Lancet Psychiatry, 3(5), 415–424. https://doi. org/10.1016/S2215-0366(16)30024-4 Mcray, J. (2015). Attachment theory | Leadership Glossary: Essential Terms for the 21st Century - Credo Reference (1st ed.). Missinon Bell Media. Meichenbaum, D. (1977). Cognitive-Behavior Modification. Boston, MA: Springer US. https://doi.org/10.1007/978-1-4757- 9739-8 4
YOU ARE NOT
ALONE!
Generalized Anxiety DISORDER
Cognitive behavior theory
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NXIETY can be a crippling experience. In essence, it is our body’s response to conceivable future fear, and part of our survival instinct. Let’s imagine a cave man who saw a pack of wolves around the source of drinkable water. The cave man feels anxious to return to the pond, but he has to. As he gets closer to drink water, his body starts to react to potential danger. His body switches into an alert state by breathing faster, elevated heartbeat, tension in the muscles, he can only think about the threat nothing else. Does that sound familiar? Although it is unlikely to be involved in a similar situation today, our bodies response remains as same. As intellectual beings anxiety often manifests as worry. In fact, we are surrounded by worry. Students worry about their grades, parents about the children’s future, business people about profit. Nonetheless, anxiety can be a drive to move us forward too.
Fear and anxiety are emotions, just like anger and happiness. All emotions can be felt in different intensity. What happens if we feel anxious all the time or if we experience anxiety intenser than others? American Psychiatric Association specifies the condition of excessive worry or difficulty of controlling worry as (GOD) Generalized Anxiety Disorder (2013). GOD patients suffer from problems of focus and concentration, sleep issues, restlessness, irritation and muscle tension. One of the best-known treatment of generalized anxiety disorder is (CBT) Cognitive Behavior Therapy. CBT is a type of psychotherapy combines cognitive, behavioral, developmental, biological and social theories. So, how does CBT helps to reduce anxiety? CBT claims that our reactions are affected by thoughts, believes. However, our thoughts and beliefs are
7% OF THE WORLD POPULATION ARE SUFFERING FROM ANXIETY (Chisholm et al., 2016)
“don’t worry, get Cbt” often distorted. Let’s take an example of a wedding. Groom is happy to set up a new family, while bride feels anxious because of the pressure building up a new family. Meanwhile, brides older sister feels abandoned and ugly. She believes that she is unlovable. Have you noticed, how the same situation invoked different emotions with different intensity? We often believe
that our emotions are absolute truth, but in fact, it is just information about how we feel. In reality, bride’s sister is in a beautiful dress, but she fails to see others trying to meet her because she feels that it is not possible. CBT aims to change negative automatic thoughts which are the manifestation of the distorted thinking in short amount time.
BIOLOGICAL THEORY, GAD AND TREATMENT
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EAR is a strong emotion, and a natural survival tool. Therefore, there is a biological response in the body. We used the example of the cave man. Let’s assume that the cave man encounters the wolf pack! What happens? Cave man needs to make a decision. He will either FACE the threat or FLEE. This is called fight or flight response. During fight or flight, our body trigger series of reactions in nervous, cardiovascular, respiratory, endocrine and excretory systems. Everything starts in the brain. Amygdala which is believed to control emotions invoke hypothalamus. Hypothalamus send a message to the sympathetic nervous system which initiates the fight or flight response. During a potential
threat, the body switches into high energy mode. All unnecessary functions such as digestive system are turned off. Instead, energy and blood flow are redirected into muscles. To be able to support the high energy consumption respiration increases. Extra oxygen is pumped faster to the cells. Meanwhile, adrenaline and noradrenaline are released for extra energy.
fight or flight response can impair your daily functions at high capacity. Even if you manage to hide the symptoms, high energy mode will exhaust the body eventually. You will have troubles to focus, sleeping problems, muscle tension. In most cases, anxiety attacks are so uncomfortable that the brain starts to feel anxious about the next anxiety attack.
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HE elevated high energy mode cannot be maintained forever. The body activates the fight or flight with every perceived threat including anxiety triggers. Imagine that you are having and anxiety attack in a business meeting.Without an actual threat, the
YMPTOMS of the fight or flight can be induced with medication or CBT. Pharmaceutical solutions seek to chemically induce brain’s reaction. Meanwhile, Cognitive Behavioral Therapy helps the patient to realize that perceived threat is not real.
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Cognitive development theory and approaches to gad
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UST as it is possible to also fail to show interest inherit biological and when others are under stress. psychological problems from the family. It is also possible I N S E C U R E / to learn some of it. We learn A M B I V A L E N T some of our anxieties as a ATTACHMENT; child child. Let’s take the example rejects the attachment figure of a child playing in the when engaged.Often happens garden who stung by bees. when the parent does not Just like an adult, child’s respond to the needs of the body also initiates fight or child. flight response. Pioneering psychologist Jean Piaget DULTS tend to build suggests that children do similar attachments as not have same cognitive they did in the childhood, capabilities as adults. but attachments are not (Barrouillet, 2015) Therefore, the only stimuli affects the the child does not have the behavior. Throughout years, emotional capacity to deal we accumulate information, with complex emotions such thoughts and believes which as intense fear. If unattended, become patterns of behavior the child may develop anxiety called schema or schemata disorder which might lead to (plural). The cognitive object-specific Developmental anxiety called “adults tend approach uses the phobia. Schemata Therapy to imitate So, why is that to threat distructive pattern of everybody behavior. attachment does not d e v e l o p BT and behaviors p h o b i a S c h e m a from the from their therapy uses childhood” childhood? similar approaches. According to However, Schema Ainsworth and therapy used to Bowlby’s attachment theory; treat patterns of disruptive caretaker (in most cases behavior by helping the parents) provide emotional client meet the unmet needs, support which helps the while CBT focuses on the child to relieve stress, feel cognitive process at the secure, and build health moment. For example one self-image (Mcray, 2015). of the techniques used in Consequently, when the schema therapy is limited rechild got stung by the bee, parenting which is performed he/she cries. Mother removes by therapist assuming the the child from the dangerous position of parent. Let’s go environment, reassures the back to the example, the child child that he/she is safe. who stung by a bee which Ainsworth and Bowlby developed a phobia of bees concluded that children can be treated with schema displayed three distinctive therapy by fulfilling the need patterns of attachment. of secure attachment. (Mcray, 2015) S E C U R E P until now, we ATTACHMENT; learn that cognitive majority if people feel development shape our adult safe to attach others thinking. Furthermore, we are also affected by behavior INSECURE/ AVOIDANT we witness around us. This ATTACHMENT; often concept is known as social described as independent. imitation Does not seek others comfort in times of stress,
behavioral theory and application
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0TH-CENTURY psychology dominated by the idea of altering behavior. However, unlike most branches of science, the behavior is hard to measure objectively. Therefore, behaviorist such as Pavlov and Watson ( later they will be called classical behaviorist) choose to ignore, beliefs, feelings, and cognition, instead they focused on a technique called classic conditioning. (Meichenbaum, 1977) Classic conditioning which reduced all behaviors into stimulus and response.
ATTACHMENT PATTERNS
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In the second part of the century, behaviorist view starts to migrate into operant conditioning. Unlike classical conditioning, the new approach accounted the subjects feeling and feelings. To be able to modify behavior operant conditioning used the following techniques:
Social Imitation Theory
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OCIAL psychologist Bandura claimed that learning is possible by observing, modeling and imitating others. (1989). His model define following terms; • Model: the person with desired behaviors • Verbal instructions: verbal description of desired behavior. • Symbolic:Envoironment around a person such as television, music, book, cultural norm understanding
• P O S I T I V E REINFORCEMENT: Stimuli is used to teach or reinforce desired behavior. The most known example is giving your dog a treat to teach sitting.
Bandura was the first scientist to study effects of violence on others. His famous experiment Bobo Doll experiment proved that behavior could be learned by imitation others. Later he explained that attention, retention, reproduction, and motivation are steps of social learning. Social Learning techniques are used to increase selfcontrol, reinforcing behavior, support. One of the best known examples is the Alcoholic Anonymous- Twelvestep program which aims to introduce patients as sponsors to teach successful behavior. In the program, patients are encouraged to meet others whenever feel vulnerable.
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REINFORCEMENT: used by removing something unpleasant after the desired behavior exhibited. Not allowing the play until homework is finished is an example parents often use. • P O S I T I V E PUNISHMENT: used by introducing unpleasant outcome when undesired
“Behavior can be changed for better or worse” behavior is exhibited. Putting money to jar, everytime child cusses is an example of positive punishment. • N E G A T I V E PUNISHMENT: Removing something desired when unwanted behavior is exhibited. Taking away bonus when an employee is late to work is an example of negative punishment. The therapist often uses such techniques with different schedules to change the outcome of the behavior.
CBT explains that behaviors can affect or change cognition. For example, a patient with social anxiety disorder tends to feel biological symptoms of anxiety ( as we discussed earlier) when surrounded by others. If untreated, such behavior might reinforce the idea of avoiding situations or places for the sake of feeling safe or well, which can turn into agoraphobia. Do you see that how behavior can affect the way think as well? It is possible to learn good behavior as much as the bad. Cognitive Behavioral Therapy can help you to change malicious or unwanted behaviors. CBT therapist often uses techniques such as interoceptive exposure by exposing the patient to anxiety trigger. You will receive help facing the fear instead of avoiding it. In this way, your body will learn new healthy responses, and you will see that anxiety responses are not dangerous, it is just uncomfortable. Finally, you can learn how to deal with anxiety even without a therapist.
cognitive theory and application Cognition is the process of receiving and understanding information, and it is subjective. Let’s imagine that a family visits a therapist at the office, and reading this booklet. The father can think that this information is boring, while mother finds it very interesting, and the child feels relieved because the symptoms are similar, and he knows that there is a solution. As you can see that similar circumstance created different reactions. This is because the reactions are shaped by thoughts, believes and interpretations. The cognitive model explains that events processed by cognition create emotions. Emotions are sourced from the beliefs. The father in the example thinks that booklet is boring because he believes that psychology does not work, even though he never received therapy. Cognitive theory calls such thoughts or behavior as distorted thinking or cognitive distortions. All through the example is negative; beliefs can be positive as well. The father of CBT Beck said that our beliefs are affected by principles named core beliefs, and often goes back to our childhood (1979). In our daily life, core beliefs often exhibit as negative automatic thoughts. The father’s negative automatic thought is “therapy never helps anybody, it won’t help my family” is an example. Unchecked negative automatic thoughts can lead to serious problems, such as anxiety and phobias. CBT helps patients to be aware of their negative thoughts and helps them to change disruptive behavior.
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COGNITIVE THEORY TECHNIQUES The cognitive approach claims that malicious or excessive behavior is exaggerated form of normal behavior. This proposition is called the “continuum principle”. Beliefs such as sick or crazy do not belong in CBT. We learned that negative automatic thoughts are the source of our exaggerated behavior, and it is essential that the client see it as well. Therefore, CBT therapist uses a technique called Socratic questioning or guided discovery. For example; a client suffering from generalized anxiety disorder believes that if she fails the exam, she can not get the diploma. Therefore she will not find a job, and she will be forced live with her family until they force her to marry someone she doesn’t love. Do you see the train of negative automatic thoughts? In this case, the therapist asks serious of questions to figure that she actually studied a lot and in fact, she scored good results in practice tests. The realization of excessive behavior and thoughts are the first step to solve the problem at its root. The guided discovery is a process. CBT encourages patients to spot negative automatic thoughts themselves. For example, the patients are often asked to keep journals to spot their thoughts which helps them to see how much such thoughts affect their lives.
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