ANGER

What is anger?

Anger is an emotion everyone has felt at times. There will always be moments (and people) in life that push our buttons and try our patience. There is nothing wrong with feeling anger. It is how we react to it and express it that gets us into trouble. We hurt the people we love most with our words and behavior. We hurt ourselves, physically and emotionally, by holding on to these angry feelings. These feelings, if not appropriately managed and expressed, can lead to bitterness and resentment, which makes for an unhappy life.
 
The good news is that it is quite possible to learn how to manage your anger, and it begins with examining your thoughts. Examining the relationship between your thoughts, moods, and behaviors will help you understand your triggers, how you tend to respond to these triggers, and the repercussions of your typical response. By practicing new reactions, you can begin to incorporate more effective responses into your daily life.
 
How does Cognitive-Behavioral Therapy treat anger?
 
In cognitive-behavioral therapy, the therapist will help you identify “hot” and “cool” thoughts. Hot thoughts are the thoughts you have when your anger is at its peak. Therapy will offer a safe environment to challenge these hot thoughts and adapt them into more balanced and effective (“cool”) thoughts. CBT will also help you identify possible distortions in the way you are thinking about a situation, challenge you to determine the validity of these distortions or perceptions, and then reframe the thought into something more adaptive.
 
CBT will:

• Help you understand the situations and interpretations of those situations that have led to your feelings of anger
• Help you modify the interpretations and underlying beliefs that led to your feelings of anger
• Teach you how to identify prompting events that trigger your anger (for example: relationships, work situations, minor irritations, financial problems, high expectations that haven’t been met, etc.)
• Assist you in determining new behaviors and responses in situations that trigger your anger.

This will be done using several techniques:

• Thought Records
• Using a written technique called a “thought record”, you will write down your hot thoughts and work with the therapist to modify them into cool thoughts. There are common distortions in thought that are connected with anger, including labeling (“He’s always such a jerk”), mind-reading (“She thinks I’m inadequate”), and magnification (“I can’t deal with this!”). You will learn which one(s) you tend to rely on and how to adjust them.
• Skills Training
• Emotion Regulation Skills: It is important to understand the emotions you are experiencing – to understand what purpose they serve. Emotion regulation training will help you learn how to decrease the negative emotions and thoughts and increase the positive emotions and thoughts.
• Mindfulness
• Mindfulness refers to what we pay attention to. Mindfulness techniques will help you harness your awareness rather than allowing it to wander around or get out of control, which often happens when we are upset. Mindfulness will teach you to focus on something other than your thoughts, which will then naturally calm your emotions.

CBT techniques for managing anger are extremely effective in helping clients understand and modify reactions and underlying beliefs that have caused their anger. The effects of this understanding have wide-ranging benefits, including better communication with others, healthier relationships, and higher self-esteem.

Acceptance and Commitment Therapy (ACT)



Acceptance and Commitment Therapy is a newer form of CBT that focuses on your behavior to a greater extent than thoughts. Thoughts, emotions (such as anger), memories and sensations are accepted rather than evaluated. Attention is turned towards moving your behavior to the life that you want.

ANXIETY

What is anxiety?

Anxiety is a combination of physical and psychological symptoms that emerge when we are faced with a threat. Anxiety may range in intensity, frequency, and impact on the person. When a person is struggling with anxiety, he or she may experience intense fears coupled with physical arousal, including rapid heartbeat, quick and shortened breathing, and perspiration.

Symptoms of anxiety include:

• Restlessness or feeling keyed up or on edge
• Being easily fatigued
• Difficulty concentrating  or mind going blank
• Irritability
• Muscle tension
• Sleep disturbance

These emotional and physical responses to anxiety are experienced as aversive and out of the individual’s control. In result, the sufferer may find any way possible to avoid the feared situations or people. While avoidance may initially bring emotional relief, it maintains the avoidance cycle, limits the individual’s range of activity, and heightens anxiety (Wright, Basco, & Thase, 2006).

Anxiety is quite normal and almost everyone experiences it at some time in their lives. The prevalence of anxiety has risen in the last fifty years as American society becomes less socially connected. Approximately 19 million Americans struggle with an anxiety disorder (Leahy, 2009).

Anxiety Disorders may include:

• Generalized Anxiety Disorder
• Obsessive-Compulsive Disorder (OCD)
• Panic Disorder
• Post-Traumatic Stress Disorder (PTSD)
• Social Phobia (or Social Anxiety Disorder)

What causes anxiety?

Anxiety is caused by a number of biological, environmental, and psychological factors. Anxiety is a natural, active defense to danger. We may refer to anxiety as the fight, flight, or freeze response that all animals are born with – it protects us and ensures survival. Anxiety can serve a very adaptive purpose in this regard.

The anxiety response is not only genetic but learned. A person’s body learns to react with anxiety symptoms when fear consistently accompanies a situation or person. As a result, the individual may interpret these situations (and related ones) as dangerous or threatening and avoid them in the future. The good news is anxiety can be unlearned!

Treatment with Cognitive-Behavioral Therapy (CBT)

The treatment of anxiety in CBT involves unlearning the feared response. When you begin treatment, the therapist may assess your symptoms, triggers, and coping strategies, help you identify targets for treatment, and provide basic skills training. Relaxation, breathing training, distraction, and de-catastrophizing are some skills that you may learn. The client practices these skills while gradually engaging in behavioral experiments that help him or her confront the fear. You may also work on modifying beliefs about the feared situation/person and learn to interpret fears in ways that help you cope and increase your range of valued activities. If you are struggling with anxiety, making progress will require being uncomfortable for tolerable amounts of time. In your treatment of anxiety, you may also practice surrendering control (Leahy, 2009).

References:

Leahy, R. (2009, April 30). CBT Approaches to Treatment Resistant Anxiety. Lecture presented at Harbor-UCLA, Torrance, CA.

Wright, J.H., Basco, M.R., & Thase, M.E. (2006). Learning cognitive-behavior therapy. American Psychiatric Publishing, Inc. 

Additional Information Online:

American Psychiatric Association. (2009). www.HealthyMinds.org

Anxiety Disorders Association of America. www.adaa.org

National Institute of Mental Health. (2009, March 30). Anxiety disorders. Retrieved June 16, 2009, from http://www.nimh.nih.gov/health/publications/anxiety-disorders/complete-index.shtml

National Mental Health Organization. (2009). Fact sheet: Anxiety disorders. Retrieved June 16, 2009, from http://www.mentalhealthamerica.net/go/information/get-info/anxiety-disorders 

Books:

Burns, D. (1999). The feeling good handbook. Penguin: New York, NY

Forsyth, J. P. (2008). The mindfulness and acceptance workbook for anxiety: A guide to breaking free from anxiety, phobias, and worry using acceptance and commitment therapy. New Harbinger Publications.

Greenberger, D. (1995). Mind over mood: Change how you feel by changing the way you think. Guilford Press: New York, NY

Leahy, R. (1996). The worry cure: Seven steps to stop worry from stopping you. Three Rivers Press

Leahy, R. (2009). Anxiety free. Hay House.

Lejeune, C. (2007). The worry trap: How to free yourself from worry & anxiety using acceptance and commitment therapy. Oakland, CA: New Harbinger.


BORDERLINE PERSONALITY DISORDER

What is Borderline Personality Disorder?

Borderline Personality Disorder, or BPD, is a diagnosis given to individuals who display many or all of the following behaviors:

• Fear of being abandoned or left alone
• Having unstable relationships that alternate between love and hate for another
• Having an unstable self-image or no identity
• Engaging in impulsive behaviors (gambling, spending, shoplifting, sex, substance abuse, binge eating)
• Making suicidal threats, gestures, attempt, and/or engaging in self-injurious behaviors (cutting)
• Having intense mood swings and emotional overreactions
• Having feelings of emptiness
• Experiencing intense and inappropriate anger and having trouble controlling anger
• Being paranoid or losing a sense of reality

Treatment of BPD

Research has shown that Dialectical Behavior Therapy (DBT) is most effective in treating individuals with Borderline Personality Disorder. The ultimate goal of DBT is to help individuals with BPD create a LIFE WORTH LIVING.  This is done through teaching new skills to:

• Eliminate life-threatening behaviors (suicide attempts, suicidal thinking, cutting)
• Reduce behaviors that interfere with therapy (showing up late, not attending at all, not completing homework assignments)
• Decrease behaviors that destroy the individual’s quality of life (depression, anxiety, eating disorders, problems at work or school)
• Improve attention
• Improve relationships
• Understand and have more control over emotions
• Tolerate emotional pain

These goals are achieved by involving our clients in 3 modes of DBT:

• Individual psychotherapy once per week for 1 hour
• Skills group once per week for 1 ½ hours
• Phone coaching as needed

CHRONIC DEPRESSION

What is chronic depression?

Depression is a strong feeling of sadness. Often people experience depression in response to a loss or sad event, such as divorce or unemployment. However, if the strong feelings of sadness, disconnection, and loss of interest in enjoyable activities persist past six to nine months, professional help may be needed. Unlike more common forms of depression, chronic depression (sometimes referred to by professionals as ‘chronic major depression’ or ‘dysthymia’) is long-lasting, possibly going on for years with only temporary relief from symptoms.

What are the symptoms?

The individual struggling with chronic depression may have difficulty sleeping, or want to sleep more than usual. He or she may experience changes in eating habits, feelings of hopelessness, low self-worth, low energy levels, restlessness, loss of interest in normal activities, difficulty maintaining relationships, decreased sex drive, feelings of guilt for no reason, and difficulty maintaining relationships. People with chronic depression have at least two of these symptoms for a period of two years or more. People with chronic depression can be gloomy and extremely critical of themselves and others. Due to the constant struggle with depressive symptoms, they may also be seen by others as extremely negative people, who seem to expect failure and take no pleasure in anything.

How is it treated?

Thankfully, there are treatment options for the individual struggling with chronic depression. Often typical treatments such as supportive therapy and psychotropic medications alone are not enough to help treat such a long-term problem. It is strongly recommended in the mental health literature for patients with chronic depression to participate in consistent, behaviorally-focused treatment along with a regime of anti-depressant medication. A treatment protocol called Cognitive Behavioral Analysis System of Psychotherapy (CBASP for short) introduced by James P. McCullough from Virginia Commonwealth University is a promising cognitive-behavioral treatment that has been shown to help the chronically depressed patient recover from years of disconnection and dissatisfaction with their life and relationships. All of CBT California’s clinicians are intensively trained in CBASP treatment by Dr. McCullough and continue to receive on-going supervision from him to ensure fidelity to the model.

Where can I get more information on CBASP and the treatment of chronic depression?

Visit www.cbasp.org to connect to resources, books, the CBASP patient manual, and review articles outlining the scientific support for this approach to chronic depression.

Read “Treatment for Chronic Depression: Cognitive Behavioral Analysis System of Psychotherapy” by James P. McCullough, PhD to learn more about the theory and practice of CBASP.


DEPRESSION



What is depression?

Everyone experiences periods of time when they feel sadder or more down than usual. This is both normal and expected—decreases in mood are natural responses to certain life experiences (e.g. stress, the death of a loved one, or the end of a significant relationship). But when is a decrease in mood a sign of depression? Depression is not the same as simply feeling sad; someone who is experiencing depression may feel sad, but he or she must also experience a number of other symptoms that considerably impair the quality of his or her life.

What are the symptoms of depression?

Not all depression looks and feels the same. Depression may vary greatly in intensity level, the amount of time you have felt depressed, and the number of noticeable periods you have felt depressed. It is important to note that all types of depression, mild through severe, have the potential to significantly affect your life (e.g. your ability to function at work or the quality of your personal relationships). The following list includes some of the most common symptoms of depression:

• Feeling depressed or down most of the time
• Losing interest or pleasure in things you usually enjoy
• A large increase or decrease in your appetite or weight
• Sleeping too much or not being able to sleep enough
• Feeling either very tired or as if you have lost most of your energy
• Feeling worthless or having low self-esteem
• Feeling hopeless
• Feeling extremely guilty for reasons you may not be able to explain
• Having difficulty concentrating or making decisions
• Having recurrent thoughts of death
• Having recurrent thoughts of wanting to commit suicide

What is Cognitive-Behavioral Therapy and how does it treat depression?

Cognitive-Behavioral Therapy (CBT) is a scientifically researched type of psychotherapy that looks at how our thoughts, behaviors and feelings strongly affect one another; it has been proven to be the most effective treatment for depression. CBT works to help people evaluate and respond to negative thoughts and behaviors because these unintentionally contribute to and help to maintain depression.

Example: If you have the thought, “I always do a bad job at work,” how do you feel? Does that thought make you feel better or worse? It’s pretty likely that this thought makes you feel upset, and maybe even sad or depressed. If you felt upset or sad about your performance at work, how would it affect your behavior? Would you want to try harder at work or try less? Would you even want to go to work? It’s a good guess that you would probably try a lot less if you were feeling bad about your job performance and believed that you were doing a bad job any way. You may then end up performing poorly at work because you have not felt like trying, and the thought “I always do a bad job at work” pops up once again and the cycle starts over.

We do not mean to say that depression is easily solved by simply changing how you think; Cognitive-Behavioral Therapy simply gives you a way of better understanding how your negative thoughts affect how you respond to different situations, and in turn, how you feel. Most importantly, CBT gives you the specific tools to change these negative thoughts and behaviors so you will be able to work your way out your depression.


EATING DISORDERS

What is an eating disorder?

An eating disorder is serious and potentially life-threatening problem characterized by extreme attitudes, behaviors and emotions about eating, body image and weight. Behaviors can include extreme restriction in food intake, overeating, compulsive exercise, and various methods of purging. 
 
What are the symptoms of eating disorders?

Anorexia Nervosa (AN): 

A condition characterized by self-starvation, excessive weight loss, and an intense fear of gaining weight.

Symptoms include:

• Refusal to maintain body weight at or above a minimally normal weight for height, body type, age, and activity level
• Intense fear of weight gain or being "fat"
• Loss of menstrual periods in women
• Extreme concern with body weight and shape

AN is associated with several potentially life-threatening physical complications, including: 

• osteopenia (thinning of the bones)
• mild anemia and related muscle loss/weakness
• low blood pressure and slowed pulse
• delayed growth lethargy
• severe constipation
• drop in internal body temperature

Bulimia Nervosa (BN):

A condition characterized by a cycle of binge eating and compensatory behavior.  Binge eating is defined as eating a large amount of food in a limited period of time while feeling unable to stop eating.  Compensatory behaviors are untaken to rid the body of calories (i.e., to “undo binge eating) and include both purging (e.g., self-induced vomiting, laxatives, diuretics) and non-purging (e.g., fasting, excessive exercise) forms.  Unlike individuals with AN, individuals with bulimic nervosa are normal weight or overweight. 

Symptoms include:

• Repeated episodes of bingeing and purging
• Feeling out of control during a binge and eating beyond the point of comfortable fullness
• Purging after a binge (typically self-induced vomiting, abuse of laxatives, diet pills, and/or diuretics, excessive exercise, or fasting)
• Frequent dieting
• Extreme concern with body weight and shape

BN is associated with several potentially life-threatening physical complications, including:

• severe dehydration from purging fluids
• swollen glands in the neck and jaw
• chronically inflamed throat
• gastroesophageal reflux disorder
• electrolyte imbalances
• worn tooth enamel

Binge Eating Disorder:

A condition in which individuals engage in frequent binge eating that causes significant guilt and distress but do not engage in compensatory behaviors such as self-induced vomiting or exercise.  Individuals with binge eating disorder are often overweight or obese and experience feelings of guilt and shame about the binge eating, which often lead to more binge eating.  It is also common for individuals to struggle with loneliness, anxiety and depression and physical conditions related to being overweight, such as diabetes and hypertension.  Currently, Binge Eating Disorder is classified under the category of “Eating Disorder Not Otherwise Specified.”

Other Eating Disorders:

Many individuals experience several symptoms of eating disorders without meeting full criteria for either AN or BN.  Treatment is frequently warranted because the symptoms cause significant distress and impairment.  These individuals are typically diagnosed with “Eating Disorder, Not Otherwise Specified.”
 
What Causes Eating Disorders?

There is no one cause of eating disorders.  Risk factors are generally understood as a combination of genetic, biological, psychological, social, and cultural factors. 
 
Genetic

Recent research suggests strong evidence that eating disorders run in families.  Several different genes and genetically-transmitted traits have been implicated as potential sources of genetic risk factors.  However, more research is needed before any conclusions can be made. 
 
Biological

Research has found some evidence that individuals with eating disorders have low levels of serontonin, a chemical in the brain associated with both mood and appetite.  There is also some evidence that chemicals associated with stress levels are abnormally high among individuals with eating disorders.
 
Psychological

Low self-esteem, perfectionism, depression, anxiety, feelings of lack of control or inadequacy and a tendency to experience negative emotions (i.e., neuroticism) have all been suggested as risk factors for eating disorders.
 
Social

Family conflict, teasing or pressure from peers about weight, and experiences of trauma, especially early in life have all been identified as potential risk factors for eating disorders.  In addition, there is some evidence that difficulties in romantic relationships increase risk for eating disorders.
 
Cultural

Cultural norms that value thinness and beauty and place emphasis on having the “perfect body” have frequently been identified as risk factors for eating disorders.   As a result, the media has often been implicated in the rise of eating disorders over the past 30 years, because images of thin celebrities are thought to perpetuate unattainable ideals of thinness and beauty. 

What Treatments Are Available?

Anorexia Nervosa

Treatment for AN involves two primary components: weight restoration and psychotherapy.

1. Weight restoration

The first and most important goal of treatment for AN is weight gain.  Malnutrition, low energy, and other consequences of self-starvation make typical psychotherapy a significant challenge.  Thus, treatment should initially focus on restoring the individual to a healthy weigh through collaboration with a medical doctor and/or nutritionist.

      2.  Psychotherapy

Cognitive Behavioral Therapy (CBT): CBT for AN focuses on:

1) Providing the patient with psychoeducation about the nature and consequences of AN;

2) Identifying, challenging, and reshaping the patient’s distorted thoughts about food, eating, and body image;

3) Exposing patient to “feared foods,” such as those high in fat and/or calories to reduce the patient’s fears about consuming such foods, reducing restriction, and normalizing eating behavior

Family Therapy

1) Traditional Family Therapy: Therapies such as Structural Family Therapy focus on roles, conflicts, interaction patterns and alliances within the family that likely contribute to or sustain the patient’s eating disorder

2) Family-Based Therapy: Time-limited therapy that places parents in charge of feeding and monitoring the patient. Parents generally maintain control until the patient has returned to a healthy weight and can demonstrate at least some willingness and ability to manage her own eating behaviors.  Parent-training has also recently been translated to the treatment of eating disorders.  This form of family therapy instructs parents in behavior management to help them reinforce healthy behaviors and reduce unhealthy behaviors in the patient by using traditional behavioral strategies, such as rewards and punishment.

Other Psychotherapies:

Other therapies that have been shown to be helpful in the treatment of AN include Interpersonal therapy and psychodynamic approaches.  Recently Acceptance and Commitment (ACT) has also been translated for the treatment of AN.   ACT utilizes mindfulness and acceptance-based principles to encourage individuals with AN to consider alternatives, namely in the form of valued action, to the emotional and psychological traps of control around eating and body image.

Bulimia Nervosa and Binge Eating Disorder

Like AN, treatment for BN and, to a lesser extent BED, involves consultation with medical doctors and nutritionists who can monitor the patient’s health and provide the patient with an appropriate meal plan.

1. Psychotherapy

Cognitive Behavioral Therapy (CBT).

Research strongly supports the effectiveness of CBT to treat BN. CBT can be done individually or in groups. Treatment focuses on:

1) Providing psychoeducation about the nature and consequences of binge eating and purging (when applicable).

2) Identifying, challenging and reshaping faulty thinking about food and body image.  For instance, therapists will help patients identify “all or nothing” thinking about food and challenge assumptions about the importance of appearance.

3) Identifying triggers for binge eating (and purging when applicable).

4) Developing alternative behaviors to cope with stress and difficult emotions, such as sadness and anger. 

5) Reducing extreme dieting behaviors, such as fasting, restriction, and binge eating. 

Family Therapy. 

Family therapy for BN and BED are similar to the options described above for AN.

Other forms of psychotherapy. 

Other therapies shown to be effective for treating BN include Interpersonal Therapy, Acceptance and Commitment Therapy (ACT) (see above for description) and Dialectical Behavioral Therapy (DBT).  DBT focuses helping patients experience and accept emotional and behavioral struggles while, at the same time, providing them with skills to cope and change these problems.  Skill instruction focuses on four primary areas: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness.  It remains unclear whether these therapies are also effective for BED. 

      2.  Medications

The FDA has approved the use of Prozac (Fluoxetine), which has been shown to reduce binge eating and purging, reduce chances of relapse, and improve attitudes about eating.

Where Can I Get More Information?
 
Websites:

National Eating Disorders Association (NEDA) (http://www.nationaleatingdisorders.org/index.php)

National Institute of Mental Health (NIMH) (http://www.nimh.nih.gov/health/publications/eating-disorders/complete-publication.shtml#pub3)

National Alliance on Mental Illness (NAMI) (www.nami.org)

Something Fishy (www.something-fishy.org)
 
Books for Patients and Families:

“When Your Child Has an Eating Disorder” -- Abigail H. Natenshon (http://www.gurze.com/productdetails.cfm?PC=1405)

“When Dieting Becomes Dangerous” -- Deborah M. Michel, Ph.D., Susan G. Willard, L.C.S.W. (http://www.gurze.com/productdetails.cfm?PC=1397)
“Body Image Workbook” –Thomas F. Cash (http://www.gurze.com/productdetails.cfm?PC=1147)

Books for Clinicians:

“Cognitive Behavioral Therapy and Eating Disorders”—Christopher Fairburn (http://www.gurze.com/productdetails.cfm?PC=1661)

“Eating Disorders Review, Part 1”—Stephen Wonderlich, James E. Mitchell, Martina de Zwaan, and Howard Steiger (http://www.gurze.com/productdetails.cfm?PC=1206)
 
Referrals for Cognitive Therapists in Your Area:

www.academyofct.org


EMOTION REGULATION



What is Emotion Regulation? 

Everyone experiences emotions—whether enjoyable or painful, our emotions make us human. However, some individuals can experience emotions in an intense, labile (quickly changing) way. Depending on how one is taught to understand and cope with feelings, some emotionally sensitive individuals may have developed difficulties regulating their emotions. ‘Emotion regulation’ refers to the ability to observe, describe, experience, and express emotions without harming oneself or disrupting important relationships.
 
What are signs that I may have difficulties regulating emotions?
 
Emotion regulation problems can show up in a number of different ways for emotionally sensitive individuals. Sometimes one may feel detached from their emotions, (often described as numb, checked out, or on auto pilot). At other times it results in difficulty coping with deep sadness, overwhelming guilt, or intense anger. Because the emotions are so intense, they often drive behavior and the individual feels “out of control,” focusing much of their attention on escaping the pain in any way possible. For individuals with emotion regulation problems, they may cope with stress by flipping back and forth from distant and numb to dysregulated and in intense emotional pain. For many people, these experiences eventually take a toll on their self-esteem and can even damage important relationships in personal, work, and community settings.
 
How is it treated?
 
The important thing to realize is that going to therapy to treat emotion regulation problems does not mean your painful emotions are bad, are not important, or that you should try to get rid of them. In fact, for some individuals many problems in regulating emotions can be traced back to invalidating childhood experiences that resulted in myths and misunderstandings around the role of emotions in one’s life.
 
Emotion regulation is simply a set of skills that need to be learned and practice with the consistent support of challenging but validating therapist. Emotion regulation skills help individuals understand how their emotions work so that they can experience and express emotions in effective ways. Mindfulness-based therapy techniques such as Dr. Marsh Linehan’s Dialectical Behavior Therapy (DBT) have been shown to be extremely helpful for those struggling with emotion regulation problems. CBT California offers individual and group skills classes specifically focused on teaching the use of healthy emotion regulation skills and decreasing confusion and chaos around feeling intense emotions.
 
Where can I get more information on it?
 
Check out www.dbtselfhelp.com for more information on DBT skills modules and the scientific evidence supporting a Mindfulness-based/Cognitive Behavioral approach to emotion regulation problems.


HEALTH ANXIETY/HYPOCHONDRIASIS

What is Health Anxiety/Hypochondriasis?

Health anxiety, also known as hypochondriasis, is preoccupation or excessive worry about one’s physical health or a particular body part.  Often times individuals may worry they have a disease or life-threatening illness, causing a great deal of distress. The level of worry and preoccupation often interferes with other aspects of the person’s life, such as relationships, work, and/or school. Oftentimes, those suffering with health anxiety seek out medical professionals to dissuade their worry. However, the results often are inconclusive or do not indicate a serious physical illness, heightening the anxiety even further. Individuals with health anxiety often experience other psychological problems, including depression, obsessive-compulsive disorder, and substance use disorders.  This co-morbidity may make diagnosis and treatment of health anxiety more complex.

What are some signs of Health Anxiety/Hypochondriasis?

Excessive worry or preoccupation with physical illness or a physical deformity.  This may manifest as:

• Looking in the mirror
• Picking
• Checking the internet or medical publications for symptoms of physical health problems
• Asking family or friends for reassurance about physical functioning or appearance of the perceived deformity
• Frequently calling physicians, scheduling physician appointments, or visiting the ER to address concerns about physical health
• Visiting multiple doctors in an attempt to have health concerns addressed
• Stress and physical symptoms of anxiety, such as stomach cramping, nausea, hyperventilating, headaches, backaches, difficulty swallowing, difficulty sleeping and/or restlessness

Individuals with health anxiety often do have physical health problems, but the level of stress and anxiety associated around their health is often so debilitating it begins to interfere with day-to-day activities.

What is the treatment for Health Anxiety?

Both behavioral (how one acts) and cognitive (how one thinks) interventions have been shown to be effective treatment for health anxiety.

Some behavioral interventions that can help individuals manage health anxiety are:

• Exposure: where an individual is exposed to situations that increase anxiety (e.g. looking in a mirror, swallowing repeatedly) with the goal being increased tolerance to anxiety producing situations, learning that although the bodily sensations, although possibly uncomfortable, are harmless 
• Response prevention: preventing the individual from doing the behaviors they normally do to manage anxiety (e.g. calling the doctor, checking symptoms online) and identifying alternative behaviors, such as relaxation or distraction

Some cognitive interventions that can help individuals manage health anxiety are:

• Identifying and changing unhelpful or anxiety producing thoughts about health and physical functioning, such as:
• Catastrophic thinking: “If I don’t get this headache checked, I’ll die from a brain tumor”
• Superstitious thinking: “A garlic clove a day has prevented me from getting heart disease”
• Negatively-biased thinking: “I think the doctor missed something”
• Working to restructure and change to more helpful and reassuring thoughts, which can be done by:
  • Examining evidence: what is evidence for?/against?
  • Distress tolerance: am I underestimating my ability to cope?
• Interpersonal interventions, such as assertiveness training, or how one asserts and communicates their own needs
  
• Stress management and healthy-self care, including time for relaxation, are also essential in the treatment of health anxiety

INFERTILITY STRESS

What is Infertility Stress?

Many doctors today believe there is a link between stress and infertility. The notion of “trying too hard” may actually be true! In fact, some doctors believe that up to 30% of all infertility problems may be caused by stress related to infertility. For example, researchers at the University of California, San Diego reported that, among patients undergoing in vitro fertilization, those who were most stressed were 20% less likely to achieve fertilization.  Stress appears to have a biological impact as well, by increasing levels of hormones, such as cortisol or epinephrine, which has been related to infertility. Likewise, reducing stress may help increase proteins within the uterine lining that are involved in implantation. Stress reduction may also increase blood flow to the uterus, which also affects conception. 

But which came first, the chicken or the egg? It seems that infertility results in stress and stress results in infertility, thus creating a vicious cycle for women or couples trying to become pregnant, which often ultimately results in other forms of psychological distress such as anxiety or depression.  

There are several ways in which infertility impacts functioning. When pregnancy is difficult or impossible to achieve, individuals find themselves having all kinds of negative thoughts such as:

• “This is the worst thing that could ever happen to me!”
• “I’ll never have a baby!”
• “I’ll never be happy!”
• “It’s all my fault, I should never have drank so much in college!”
• “I have nothing going for me!”
• “My marriage is going to fall apart if I can’t have a baby!”

In CBT, we refer to these thoughts as “cognitive distortions,” or thoughts that don’t necessarily hold much truth, but have a major impact on your mood and daily functioning. The power of these cognitive distortions are so strong that they can take on a life of their own and impact many areas of your life, including your work (you may start missing too many days), marriage (you may withdraw from or blame your husband or wife), other relationships (you may isolate yourself from friends and family), health (you may begin to engage in unhealthy behaviors such as excessive smoking, drinking, eating) and day to day life (you may spend an inordinate amount of time on the internet looking for answers or putting yourself on an emotional rollercoaster testing and retesting to see if you are pregnant).  Any or all of these behaviors may contribute to or result in increased stress, or psychological distress such as anxiety or depression.

What is the treatment for Infertility Stress?

Cognitive Behavioral Therapy (CBT) focuses directly on the cognitive distortions related to the current infertility. More specifically, cognitive behavioral therapists help individuals learn to identify their thoughts or cognitive distortions, examine ways they impact their behaviors and emotions, then change them in order to change emotions and/or behaviors. Practicing this over and over again in therapy sessions and in homework assignments eventually leads to a change in behaviors, thoughts, emotions, stress level, and sometimes your ability to conceive!


OBSESSIVE COMPULSIVE DISORDER (OCD)

What is OCD?

As the name suggests, Obsessive Compulsive Disorder is an anxiety disorder characterized by the presence of obsessions and compulsions.  Obsessions are intrusive, often disturbing thoughts or images that are difficult to get rid of and cause a lot of anxiety.  Compulsions are behaviors or rituals that a person performs to temporarily reduce the anxiety caused by the obsessions.
 
The exact content of obsessions and compulsions can vary by person, but there are some common clusters:

• Contamination: Individuals with contamination fears have obsessive thoughts that germs or other contaminants may cause them to become sick or die.  They perform compulsions like hand-washing, showering, sterilizing their environment, or cleaning their house to an excessive degree.
• Checking:  These individuals have obsessive thoughts that something important has not been done.  For instance, they may worry that they did not turn off the stove, turn off a light, or lock the door.  The compulsion is to check over and over that it has been done.
• Symmetry/Order:  These individuals feel anxiety if something is not in its right place, or not the same on both sides.  For example, people with symmetry obsessions may tie and retie their shoes over and over until it “feels right” on both sides, or they may spend hours arranging things in their homes.
• Hoarding:  Individuals with hoarding obsessions feel a great deal of anxiety about throwing anything away because they worry that they will need it again some day.  They may have homes that are overcrowded with papers or other items they collect and can not throw away.
• Repeating/Counting:  These individuals have obsessive thoughts that they need to repeat something a certain number of times to prevent something bad from happening.  Repeating often includes mental rituals, such as repeating a word in one’s mind a certain number of times.  A person may also have counting compulsions, such as counting tiles on the floor out loud or in one’s head.
• Religious:  Individuals with religious obsessions may have obsessive thoughts about or images of Satan, hell, or other religious figures and symbols. They may worry that they must pray or perform other compulsions to prevent something evil from happening.
• Sexual/Aggressive:  These individuals have intrusive thoughts or images of a sexual nature or about harming themselves or someone else.  They may feel guilt and anxiety over the content of these thoughts and perform compulsions to alleviate the anxiety.
  

How is OCD treated?

A specific type of CBT called Exposure and Response Prevention (ERP) has been developed to treat OCD.  This treatment targets both obsessions and compulsions.  During exposure, the therapist helps the client to face feared situations head-on and to better tolerate and reduce the anxiety associated with obsessive thoughts.  In response prevention, the therapist and client identify and eliminate compulsions that are done to reduce anxiety. The goal is to replace the compulsions with more effective ways of coping with stress and anxiety. Cognitive Therapy is also helpful in addressing beliefs that exacerabte OCD such as thought/action fusion ("I thought about doing something terrible, that means I am going to do it") and overresponsibility ("I have to make sure there are no dangers in the road otherwise people will die because of me"). Also beliefs that interfere with engaging in ERP ("it will make things worse") can be addressed and evaluated.
 
Treatment involves confronting feared situations with the help of the therapist in session, and homework assignments in which clients develop and practice the skills needed to overcome OCD on their own.  ERP is typically done gradually, starting with situations that the client considers less stressful and working up to the most feared situations. Research has shown that ERP is a highly effective treatment for OCD.


PANIC ATTACKS/AGORAPHOBIA

What is a Panic Attack?

A Panic Attack, as described by the Diagnostic and Statistical Manual for Mental Disorder, is a discrete period of intense fear or discomfort that develops abruptly and reaches its peak within approximately 10 minutes.

What are the symptoms of Panic Attacks?

• Heart palpitation
• Trembling
• Sweating
• Shortness of breath
• Feeling of choking
• Dizziness
• Fear of losing control
• Fear of dying

Panic attacks can occur alone but are most often accompanied by what is called agoraphobia.

What is Agoraphobia?

Agoraphobia is anxiety about being in places in which escape might be difficult, embarrassing, or in which help may not be available in the event of having a panic attack (either unexpectedly or by a predisposed situation). Individuals with agoraphobia tend to seclude themselves within their homes. Some can venture further from their places of safety only if they have a friend or close relative with them. Thus, the individual will often isolate and avoid all potential situations in which they may fear a panic attack may occur.

Fears often associated with Agoraphobia often include but are not limited to:

• Being outside the home
• Being in open spaces
• Being in a uncomfortable/unsafe place or situation
• Being in an enclosed area
• Being trapped
• Being in a crowd
• Standing in line
• Being on a bridge
• Traveling in a bus, train, or automobile

What Causes Panic Attacks/Agoraphobia?

Genetics

Panic disorder often runs in families. If you have family members who had panic disorder, you are about two times more likely to develop the disorder yourself. Also, women are twice as likely to develop a panic disorder; this may suggest a genetic predisposition in women.

Psychology:
 
Panic disorder sometimes begins after major life events, traumas, or life-threatening situations. Loss and separation are especially linked to the onset of panic disorder.

Physiology:

Researchers suggest that panic disorder may be caused by a physiological dysfunction in the brain. An organ in the brain called the amygdala is responsible for initiating your fear response. People with panic disorder may have an abnormally low baseline in their amygdalas, which causes sudden and unexplainable fear reactions.

The Good news?
 
Anxiety Disorders are one of the most common types of mental health problems and one of the most treatable.

What treatments are available?

   1. Medication

Medication can be used to reduce/eliminate the symptoms of anxiety and eliminate the possibility of having panic attacks by working with a chemical imbalance in the brain. Certain antidepressants have been found to be helpful with symptoms of anxiety and are often non-addictive. High potency benzodiazepine tranquilizers have also been found to be helpful when symptoms need to be reduced quickly, such as when flying in an airplane. People with anxiety may need to consult a doctor about getting on medication in addition to psychotherapy.

   2. Cognitive Behavioral Therapy (CBT)

The cognitive model of panic disorder suggests that panic attacks are a result of catastrophic misinterpretations of either benign bodily sensations or anxiety related symptoms. Anxiety is a normal response to threat/worry. Increased heart rate/palpitations is a common bodily sensation associated with anxiety. However, a person vulnerable to panic may interpret the sensation as a sign of something much more serious and this interpretation will increase their anxiety thus leading to a panic attack.

CBT for panic disorders and agoraphobia rests on the beliefs that a person has a mistaken belief that they are in danger and the anxiety is a natural reaction to the body being convinced it’s in danger. This creates a vicious cycle between bodily sensations, distorted thoughts, and anxiety, which will quickly lead to a panic attack. In order to reduce the symptoms of one’s panic disorder, a person needs to understand that the belief that they are in danger is untrue and to explore the deeper roots of this belief.

CBT for panic attacks has two components: identifying and changing the distorted thinking patterns that maintain anxiety (cognitive) and desensitizing anxiety through exposure to feared situations (behavioral). The main focus of treatment for both components depends on the individual’s specific problem. For example, specific phobias, such as a fear of heights, are very effectively treated by exposure therapy alone, whereas panic disorder without agoraphobia is very successfully treated by cognitive therapy alone. If you have a significant amount of agoraphobic avoidance along with your panic attacks, then you will need to work both on changing your thinking and exposing yourself to the situations you fear. 

CBT for panic disorders aims to challenge and reduce the person’s belief in the danger of their symptoms, therefore breaking the cycle of panic. After this is accomplished, CBT aims to reduce avoidance and safety behaviors to further challenge the person’s fears through exposure, systematic desensitization, and shaping (just name a few).

   3. Acceptance and Commitment Therapy (ACT)

ACT (a form of Cognitive Behavioral Therapy) uses strategies to help you change your behavior, such as those related to general anxiety, panic attacks, and agoraphobia. ACT uses methods that help you learn through experience such as mindfulness and acceptance to address the fearful thoughts and problematic behaviors associated with panic disorder. ACT seeks to help you lossen the grip that we allow thoughts have over our behavior. Homework can play an integral role in the application of these techniques, by supporting the in-session therapy. Homework can be especially useful because it allows the client to utilize these principles in situations that cannot be created in the therapy sessions, such as public situation for someone who struggles with a panic disorder.

   4. Other Psychotherapies

Other treatments have been shown to be helpful with panic disorders such as psychodynamic therapy and virtual reality (which is a fairly new treatment). CBT however, has shown to be the most promising and is empirically validated.

Can Patients with a Panic Disorder and/or Agoraphobia have other illnesses?

The severity of complications and depression in patients with comorbid panic disorder tend to be greater than with either depression or panic alone. The problem of comorbid panic disorders and other anxiety disorders such as simple/specific phobias and social phobias are often seen in this population. Finally, panic disorder as well as substance abuse/dependence, accompanied by depression, is seen quite often. This is by no means an extensive list of the other illnesses that could accompany an individual with a panic disorder. Illnesses such as Post Traumatic Stress Disorder and Obsessive Compulsive Disorder are frequently seen in this population. These comorbid conditions make a panic disorder more difficult to recognize and diagnose, thus making it more difficult to treat successfully than an uncomplicated panic disorder.

Where can I get more Information?

Websites/Hotlines:
 
About.com (www.panicdisorder.about.com)

Overcoming Panic Attacks (www.paniccure.com)

No More Panic-Agoraphobia (www.nomorepanic.co.uk)

National Institute for Panic Disorder Education Program (1-800-64-Panic)

Anxiety Disorders Association of America (1-301-231-9350)  

Books for Patients and Families:

Bourne, Edmond(2000) The Anxiety and phobia workbook. New Harbinger Publications Inc. Oakland, Ca.

Capps, L., Ochs, Elinor, & Bruner, J (1995). Constructing panic: The discourse of agoraphobia. Harvard College, Ocho Elnor, IL.  

Peurifoy, Reneau (1988). Anxiety, phobias and panic: A step by step program for regaining control of your life. Time Warner Book, NY.

Sheehan, David (1983). The anxiety disease: New hope for millions who suffer from anxiety .  Scribner Book Co. New York.

Wilson, Reid (1996). Don't panic revised edition: Taking control of anxiety attacks. HarperCollins Publishers, NY.
  
Books for Clinicians:

Barlow, David (2002) Anxiety and its disorders: The nature and treatment of anxiety and panic. Guilford Press, NY

Beck, A.T, Emery, G., Greenberg, A.L. (1985). Anxiety disorders and phobias: A cognitive perspective. Guilford Press, NY.

Rygh, J.L, & Sanderson, W.C. (2001). Treating generalized anxiety disorder: Evidence based strategies, tools, and techniques. Guilford Press, NY.
  
Referrals to Cognitive Therapy in Your Area

www.academyofct.org


PANIC DISORDER

What is Panic Disorder?

Panic Disorder involves experiencing repeated panic attacks and being preoccupied with the fear of future panic attacks. Panic attacks can occur unexpectedly and “out of the blue,” sometimes even during sleep, or they can occur in situations where you expect them to happen. A panic attack is thought of as the body’s “alarm reaction.” In a truly dangerous situation, the physical changes that happen during the “alarm reaction” help protect us and cope with the situation. In a panic attack, the alarm is a “false alarm” – there is no external danger, but the alarm has been triggered nonetheless.

A panic attack is defined as a sudden rush of intense fear or dread, which is usually accompanied by several of the following symptoms: racing or pounding heart, shortness of breath, chest pain or discomfort, dizziness, feeling faint or unsteady, trembling or shaking, sweating, choking sensations, nausea or abdominal distress, numbness or tingling sensations, hot flashes or cold chills, feelings of being detached or things seeming unreal, fears of going crazy, fears of losing control, and fears of dying. In a true panic attack, these physical symptoms are not caused by a medical condition or physical illness. Typically, a physician can rule out a physical cause for the symptoms experienced during a panic attack. If a medical condition or physical illness can be ruled out, then a diagnosis of Panic Disorder might be applied.

How is Panic Disorder Treated?

   1. Medication:

There are a variety of anti-anxiety medications available for people with Panic Disorder. One common type of anti-anxiety medication is Benzodiazepines (e.g., Xanax, Ativan, Klonopin). A significant problem with repeatedly using a Benzodiazepine to treat symptoms of a panic attack is that the underlying cycle that causes panic is not addressed. That is, the Benzodiazepine is more like a “Band-Aid” covering up the problem, rather than a long-term solution to the problem.

   2. Cognitive-Behavioral Therapy (CBT):

CBT is a widely used treatment for people with Panic Disorder. Based on the theory of CBT, fear is reinforced and maintained by negative thoughts and avoidance of situations. Thus, common interventions include changing thoughts and behavior.

The four primary components of CBT for Panic Disorder include:

(1) Re-education about the physical symptoms of anxiety and panic, to correct misinterpretations of them as being harmful or dangerous

(2) Training in methods for reducing physical tension, usually by breathing retraining or relaxation

(3) Repeated exposure to feared and avoided situations

(4) Repeated exposure to feared and avoided physical sensations

Given the propensity for negative automatic thoughts, CBT therapists educate clients about panic attacks as a “false alarm” of the body’s important alarm system. Therapists explore clients’ specific fears about panic (e.g., “I’m going to die,” “I’m having a heart attack,” “I’m going to lose control”) and provide important information about the scientific evidence about panic attacks. Therapists also help clients with Panic Disorder test some of these fears and assumptions.

CBT therapists also train clients to use relaxation techniques, such as deep breathing and muscle relaxation. These are not intended as ways to completely control the fear and physical sensations during a panic attack, but as a way to maintain a sense of control of one’s body.

CBT for Panic Disorder also involves exposure to feared situations and physical sensations. Systematic exposure to these situations and sensations reduces the person's fear of them, and teaches the person that the situations and sensations are not dangerous. After repeatedly experiencing feared situations, clients realize that their fears rarely (if ever) come true, and anxiety related to these situations is reduced. Exposure to specific body sensations is designed to help clients experience these sensations while realizing they are not in fact dangerous. When fear of the body sensations is lessened, so is the fear of the return of a panic attack.

   3. Acceptance and Commitment Therapy (ACT):

ACT is a new therapy that has been applied to many disorders, including Panic Disorder. ACT focuses not on reducing symptoms, but on accepting symptoms and moving in the direction of things that the client values in life. In an ACT model, the problem is not the symptoms, but the way in which individuals respond to those symptoms. In treatment for Panic Disorder, ACT focuses on decreasing avoidance of the physical symptoms of panic attacks and the feeling of intense fear. Avoiding these things often keeps the person from obtaining goals and acting in line with his or her values.

ACT interventions include discussion of attempts to control thoughts, feelings, and physical sensations, and the alternative strategies of willingness and acceptance. Through use of metaphors, therapists help clients to see what their true values are and how they can more effectively move in that direction with their lives, along with any negative emotions and experiences. Many of the aforementioned CBT techniques can be used in the ACT intervention as well.

Where can I get more information about Panic Disorder?

Websites

Anxiety Disorders Association of America (http://www.adaa.org/)

Association for Cognitive and Behavioral Therapies (http://www.abct.org/)

Freedom from Fear (http://www.freedomfromfear.org/)

Academy of Cognitive Therapy (http://www.academyofct.org/)

Books for Patients

CBT:

Mastery of Your Anxiety and Panic: Workbook (Barlow & Craske, 2006)

ACT:

Mindfulness and Acceptance Workbook for Anxiety (Forsyth & Eifert, 2008)

Get Out of Your Mind and Into Your Life: The New Acceptance and Commitment Therapy (Hayes, 2005)

POST-TRAUMATIC STRESS DISORDER

What is PTSD?

Post-traumatic Stress Disorder (PTSD) is a diagnosis for people who were exposed to traumatic events or situations but have a difficult time moving past it. Specifically, PTSD is a persistent anxiety or emotional response that continues long after the traumatic event has passed. Approximately 8% of individuals who are exposed to such trauma will experience lasting PTSD symptoms. PTSD can result from many types of severe or prolonged traumatic experiences. Such experiences may include:

• Combat exposure
• Childhood sexual/physical abuse
• Terrorist attacks
• Sexual/physical assault
• Serious accidents
• Natural disasters
• Being a witness to such things

What are the Symptoms of PTSD?

Individuals who develop PTSD have experienced, witnessed, or were confronted by an event(s) where there was actual or threatened death, serious injury, or the where the physical integrity of their self or another was in danger. The common response to these events was helplessness, intense fear, or even horror. However, PTSD specifically involves the persistent re-experiencing of the event(s) in at least one of the following ways:

• Recurrent and intrusive memories of the event, including images, thoughts or perceptions
• Recurrent distressing dreams of the event
• Acting or feeling as if the traumatic event were recurring, including a sense of reliving the experience, illusions, hallucinations, and flashbacks, including those that occur on awakening or when intoxicated
• Intense anxiety at exposure to a feeling or external event that symbolizes or resembles an aspect of the traumatic event
• Bodily reactions on exposure to something that symbolizes or resembles an aspect of the traumatic event

In addition, individuals who experience PTSD tend to avoid situations or details that may trigger their memory of the trauma, and their general responsiveness may be numbed in a way that was not so before the trauma took place. Such behaviors may involve:

• Efforts to avoid thoughts, feelings, or conversations associated with the trauma
• Efforts to avoid activities, places, or people that arouse memory of the trauma
• Inability to recall an important aspect of the trauma
• Decreased interest or participation in significant activities
• Feeling of detachment or estrangement from others
• Limited range of affect (ex: unable to have loving feelings)
• Sense of foreshortened future (does not expect to have a career, family, etc)

Many individuals with PTSD have an increased sense of arousal that was not present before the trauma, such as:

• Difficulty falling asleep
• Irritability or outbursts of anger
• Difficulty concentrating

PROCRASTINATION

What is procrastination?

A person who procrastinates will put off doing an activity until the last minute as a way of coping with the anxiety or negative feelings associated with that activity. Procrastination can occur in many areas of life including social activities (e.g., returning or making phone calls), work or school (e.g., finishing an assignment), health-related activities (e.g., making a doctors appointment or committing to a lifestyle change), and household or financial activities (e.g., filing taxes).  The anxiety or negative feelings associated with the activity can be avoided in the short-term by making the decision not to do it at that time.  However, putting it off can create more stress in the long term, since doing something at the last minute adds greater time pressure.  In addition, many other negative emotions are commonly associated with procrastinating, such as guilt, remorse, or depression.  Procrastinating also increases the likelihood that the activity will not get done in time, creating external consequences.  For instance, someone who puts off completing an assignment at work to the point that he or she turns it in late risks the disapproval of his or her boss.  Likewise, someone who files his or her taxes late must pay a penalty fee.  These consequences may, in turn, produce more worry and stress.  The long-term costs of procrastinating quite often outweigh the short-term benefit.
 
How is procrastination treated?

Cognitive behavioral therapy (CBT) can be used to treat procrastination.  One way CBT can help is by challenging the thoughts and beliefs associated with completing an activity.  Some common thoughts include:

• “I have to do this perfectly.”
• “I don’t have enough time to do this right now.”
• “I need to be in the right mood to get this done.”
• “I’d rather do something else.”
• “I have to wait until _____ happens before I can do this.”
• “I don’t know how to do this.”
• “If I wait long enough, someone else might do this for me or help me with it.”
• “If I do this now, I’ll just be expected to do more.”
• “I can’t stand doing this.”

In CBT, the therapist will help you to examine the accuracy and utility of these thoughts.  The therapist will also help you to alter the behavioral contingencies (i.e., rewards and punishments) associated with procrastination.  When you procrastinate, the reward is that you avoid short-term anxiety.  The therapist can help you to create your own rewards system for completing each small step along the way so that your rewards system becomes more reinforcing than the avoidance.  The therapist may also help you to analyze the costs and benefits of procrastinating so that you are reminded of long-term punishments if you do not complete the activity on time and long-term rewards if you do complete the activity.  In addition, the therapist may teach you other skills in tolerating negative emotions, so that you can complete activities even if they are very unpleasant.


SOCIAL PHOBIA

What is Social Phobia?

Social phobia (Social Anxiety Disorder) is a fear of one or more social situations where there might be unfamiliar people or judgment by others.  Typically people with social phobia worry that they will embarrass themselves in such a situation, either by showing symptoms of anxiety (e.g., blushing, sweating) or by otherwise acting in a way that will be humiliating to them.  The lifetime prevalence of social phobia is 1 in 8, and it is twice as common for women than for men.  The typical onset of symptoms is in the early teenage years, though sometimes is diagnosed in childhood.  Severe cases of the disorder can be extremely debilitating (i.e., few friends, unable to attain goals).
 
What are the symptoms of Social Phobia?
 
In addition to the aforementioned fear of social situations, people with social phobia experience intense anxiety in these situations, and often avoid them when possible.  Although people with social phobia are aware that their fears are unreasonable, the anxiety experienced in social situations or worrying about social situations causes impairment in functioning (e.g., relationships, occupation). 
 
What causes Social Phobia?
 
There are a number of factors that are thought to contribute to social phobia, but the specific cause is unknown.  There is likely a genetic role, as many people with social phobia also have relatives with the diagnosis.  Often previous experience(s) with embarrassment or humiliation in social settings contributes to fear of future embarrassment.  It is also thought that negative automatic thoughts in situations (e.g., “I’m going to sound stupid when I try to talk about this topic”), as well as extremely high standards (e.g., “I should not be anxious”).  Although it has long been thought that people with social phobia lack social skills, recent theory has challenged this, posing that people with social phobia are actually more attentive to social cues, and thus more sensitive to unskillful behavior.
 
What treatments are available?
 
   1.     Medication:

There are a variety of anti-anxiety medications available for people with social phobia.  One problem with medication is that anxiety symptoms often recur when the medication is stopped; for this reason many think psychotherapy is the treatment of choice.
 
   2.     Cognitive-Behavioral Therapy (CBT):

CBT is a widely used treatment for people with social phobia.  Based on the cognitive model, anxiety is reinforced and maintained by negative thoughts and avoidance of situations.  Thus, common interventions include changing thoughts and behavior. 
 
Given the propensity for negative automatic thoughts, CBT therapists help clients with social phobia test some of the assumptions that underlie these thoughts.  Clients might engage in observation of others’ behavior, behavioral experiments about others’ reactions to anxiety behavior (e.g., exercising before going to a part to test the impact of sweating in a social situation), and developing alternative explanations to others’ behavior (e.g., “John must not have seen me,” rather than “John must not like me” when friend does not make eye contact on the street). 
 
Another common CBT intervention used with clients with social phobia is exposure.  Using exposure techniques, the therapist introduces the client to the situations the client fears, first in the therapy room (i.e., imaginal or in-session role play exposure) and then in the uncomfortable social situation (i.e., in vivo exposure).  The therapist supplies the client with tools for these situations (with social skills training and relaxation training), and does not push the client to do anything the client is not ready and willing to do.  After repeatedly experiencing feared situations, clients realize that their fears rarely (if ever) come true, and anxiety related to these situations is reduced.  Clients that have gone through CBT for social phobia report that they feel less anxious, and are able to approach rather than avoid social situations.
 
   3.   Acceptance and Commitment Therapy (ACT):

ACT is a new therapy that has been applied to clients with social phobia.  ACT focuses not on reducing symptoms, but on accepting symptoms and moving in the direction of things that the client values.  In an ACT model, the problem is not the symptoms, but the way in which individuals respond to those symptoms.  In treatment for social phobia, ACT focuses on avoidance (of both feelings of anxiety and external situations) that in turn keeps the client from obtaining goals and acting in line with his or her values.  Although individuals are often able to reduce anxiety through both internal and external processes, in the case of social phobia it is virtually impossible to move toward values when so focused on avoidance of unpleasant experiences. 
 
ACT interventions include discussion of control and the alternative of willingness and acceptance.  Through use of metaphors, therapists help clients to see what their true values are and how they can more effectively move in that direction with their lives, along with any negative emotions and experiences.  Many of the aforementioned CBT techniques can be used in the ACT intervention as well, but rather than helping client to approach avoided situations to reduce anxiety, the ACT therapist helps the client to approach only situations that are consistent with their desired values rather than all feared situations.
 
Can people with Social Phobia have other illnesses?
 
Depression is common in people with social phobia.  Coping strategies (e.g., drug and alcohol use) can also become problematic.  Other anxiety disorders may also be found in people with social phobia.
 
Where can I get more information?
 
Websites

The Anxiety Disorders Association of America (http://www.adaa.org/)

The Association for Cognitive and Behavioral Therapies (http://www.abct.org/)

Freedom from Fear (http://www.freedomfromfear.org/)

Academy of Cognitive Therapy (http://www.academyofct.org/)
 
Books for Patients

CBT:

Diagonally Parked in a Parallel Universe: Working Through Social Anxiety (Dayhoff, 2000)

ACT:

Mindfulness and Acceptance Workbook for Anxiety (Forsyth & Eifert, 2007)

Get Out of Your Mind and Into Your Life: The New Acceptance and Commitment Therapy (Hayes, 2005)

Books for Clinicians

CBT:

Cognitive Behavioral Therapy for Social Anxiety Disorder (Hofmann & Otto, 2008)

Contemporary Cognitie Therapy: Theory, Research and Practice (Leahy, 2004)

ACT:

A Practical Guide to Acceptance and Commitment Therapy (Hayes & Strosahl, 2004)

Learning ACT (Luoma, Hayes, & Walser, 2007)

SUBSTANCE USE DISORDERS

What are substance use disorders/addiction? 

Based on the different theories surrounding the causes of addiction, the definition varies across schools.  
 
Addiction: A primary, chronic, and neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over medication use, compulsive use, continued use despite harm, and craving.
 
What is the difference between Substance Abuse and Addiction?

The Diagnostic and Statistical Manual of Mental Disorders IV-R describes abusers as those who abuse substances despite recurrent social, interpersonal, and legal problems as a result of using. Harmful use implies substance use that causes either physical or mental damage.
 
Abuse and addiction are not the same. Abuse always comes before addiction, which is  chronic and treatable. Abuse starts when there is a conscious decision to abuse substances. Used too often, the individual eventually craves the substance because physical changes in the brain haven taken place. Substances interfere with the brain’s natural processes by making both temporary and structural changes in brain cells. Mood, memory, thinking, and even motor skills such as walking may be affected. When this happens, drug abuse turns into addiction. People who are addicted have a compulsive craving and cannot quit by themselves.
           
What are the signs and symptoms?

Physical Signs

• Loss of/increase in appetite, any changes in eating habits
• Unexplained weight loss or gain
• Poor physical coordination
• Inability to sleep, awake at unusual times, unusual laziness.
• Red, watery eyes; pupils larger or smaller than usual; blank stare
• Cold, sweaty palms; shaking hands
• Puffy face, blushing or paleness
• Smell of substance on breath, body or clothes
• Extreme hyperactivity; excessive talkativeness
• Runny nose; hacking cough
• Needle marks on lower arm, leg, or bottom of feet
• Nausea, vomiting or excessive sweating
• Tremors or shakes of hands, feet, or head
• Irregular heartbeat

Behavioral Signs

• Change in overall attitude/personality
• Changes in friends or social circles
• Change in activities or hobbies
• Drop in performance at work or school
• Change in habits at home; loss of interest in family
• Difficulty in paying attention; forgetfulness
• General lack of motivation, energy, self-esteem
• Sudden oversensitivity, temper tantrums, or resentful behavior
• Moodiness, irritability, or nervousness/giddiness
• Paranoia
• Excessive need for privacy; unreachable/secretive or suspicious behavior
• Problems with the law
• Chronic dishonesty/stealing
• Change in personal grooming habits
• Possession of drug paraphernalia


What causes substance abuse/addiction?
 
While some researchers would say that there are a specific number of personality traits that precede the development of substance abuse one can not predict with certainty that any personality traits predispose a person to abusing substances. Therefore, we can not determine with confidence that, based on someone’s personality alone, they will become a substance abuser.
 
The medical model claims that addictions are a disease. This model states that addiction is an inherited disease, and an addicted individual is permanently ill, at a genetic level. The medical model also believes that like other medical diseases the person will remain ill even after years of sobriety.
 
The Dual Diagnosis philosophy dictates that addiction is a dual problem consisting of both physical and mental dependency on chemicals, combined with a pre-existing mental disorder and that the mental disorder needs to be treated first as the primary cause of the addiction. This philosophy supports the idea that chemical dependency leads to chemical imbalances in the neurological system, which would be then a substance induced imbalance. 
 
What treatments are available?

   Cognitive Model of Addiction (CT)

This theory is based on Aaron T. Beck’s work that examined thoughts as the originating factor of any behavior. An individual’s behavior and affect are determined by his or her view of the world and the way they structure their world. Beck’s work also explored what he called a “schemata”- a stable, mental representation of experiences that are involved in the evaluation of information. Basically, thoughts are interpreted based on experiences and activating emotions when new situations and events arise.
 
Abnormal or dysfunctional thinking occurs when systematic distortions are applied to the new incoming situations or events affecting motivations, actions, and feelings. CT is utilized to change these cognitive distortions by assisting the client to change one’s actions, motivations, and feelings by assisting the client in challenging their own dysfunctional cognitive processes. 
 
There are many reasons people use and abuse substances; they range from pleasure, creativity, experimentation, relief from sadness, anxiety or even boredom. It is the underlying belief in any reason for substance use that shape the physiological sensations linked to the cravings and usage, and eventually addiction.
 
These addicted behaviors are shaped from core beliefs that have to do with personal survival, autonomy, and freedom. An addict’s beliefs, in all three of these areas are dysfunctional. The dysfunctional thought patterns seem to take over and as the person becomes addicted, the drug appears to take control of the individual. The obstacle in addiction is eliminating the person’s dysfunctional beliefs that they hold about the substance. These dysfunctional beliefs can range from fear of side affects to the belief that they cannot function without the substance. Changing the maladaptive beliefs, thought patterns, and schemas are at the core of the CT approach for substance abuse and addiction. These beliefs must be changed in order for long-term behavioral change and sobriety.
 
In CT patients are taught to face the source that is leading to their emotional distress and to change the beliefs that substances can assist in the mending of these or any other problems. This is done by reducing the intensity and frequency of the urges by exploring the underlying beliefs and to teach the patient techniques for managing and controlling their urges. In all areas the individual’s faulty beliefs about people, events, and their views on drug and alcohol use need to be fully examined.  

   Acceptance and Commitment Therapy (ACT)

ACT, a form of CBT, uses a wide range of experiential exercises to examine the power of destructive cognitive, emotive, and behavioral processes that have contributed to and maintain substance abuse problems. It helps clients to fundamentally change their relationship with painful thoughts and feelings, to develop a clearer sense of self, to live in the present, and to take action, guided by personal values, and to create a rich and meaningful life without the use of substances.
 
ACT takes the view that most psychological suffering is caused by 'experiential avoidance', i.e. by attempting to avoid unwanted private experiences, such as unpleasant thoughts, feelings, urges & memories. The individuals efforts at experiential avoidance might work in the short term, but in the long term they often fail, and in the process, they often create significant psychological suffering. In individuals with substance abuse disorders or any serious addiction: in the short term the substance of choice makes a person feel good and helps rid of unpleasant thoughts and feelings - but in the long term, it destroys their health and vitality.
 
In ACT, clients develop “mindfulness skills” which enable them to fundamentally change their relationship with painful thoughts and feelings and the connection these thoughts and feelings have with substances. When clients practice these skills in everyday life, painful feelings and unhelpful thoughts have much less impact and influence over them. Therefore, instead of wasting their time in a battle with their inner experiences, they can invest their energy on taking action to change their life for the better - guided by their deepest values and absent of drugs and alcohol.
 
   Emotion Regulation and Mindfulness

Growing literature is supporting the importance of emotional regulation in the treatment of substance abuse. Research has mainly been done on nicotine cessation however, since nicotine and other psychoactive substances, such as cocaine, activate similar psychopharmacological pathways, an emotion regulation application may be applicable. This model focuses on negative reinforcement as the primary driving force for addiction and patients are encouraged to identify and recognize their negative and emotional states and prevent the maladaptive, impulsive, and compulsive responses that they developed to deal with them.  In the cases of addiction, these responses would be abusing substances. Like CBT this approach involves the thoughts involved in maladaptive and dysfunctional emotional states but the focus here is the reaction to those states. Therefore, this could be used in conjunction with CBT if found affective.
 
    Motivational Enhancement Therapy (MET)

MET is based on the principles of motivational psychology and is designed to produce rapid internally motivated change. This treatment employs techniques that mobilize the individual’s own change resources. CBT and MET share a focus in the beginning of exploration early in treatment of what the patient stands to lose and gain through continued substance use as a strategy to build on the patient’s own motivation to change the substance abuse. However, unlike CBT, it does not maintain that learning and practice of specific substance related coping skills promote abstinences, but instead believes that motivation to use available resources is the patient’s responsibility and therefore no training is needed. For this reason MET would work most efficiently when combined with CBT because of the focus on the different aspects of the change process.
 
Can Patients with Substance Abuse and Addiction have other illnesses?
 
As mentioned in “What causes substance abuse and addiction”, many individuals with a substance abuse problem also suffer from a psychological/mental disorder. The combination of the two tends to complicate the diagnosis and treatment. When other disorders are present the need to have multiple aspects of treatment increases significantly. Often times psychotropic medication is needed to treat a mental disorder before you can begin to work on the substance abuse problems because many individuals chose to self medicate their mental disorders with drugs and alcohol. CBT can be combined with pharmacological treatment and has been found to be affective in the reduction of substance abuse.
 
Where can I get more Information?

Websites

National Institute of Drug Abuse (NIDA) (www.drugabuse.gov)

Substance Abuse (www.drugfree.org)

Substance Abuse and Mental Health Service Organization (SAMHSA) (www.sanhsa.gov)

Alcohol and Substance Abuse (www.mentalhealth.net)

Books for Patients and Families

Anonymous (2002). Alcoholics Anonymous: The Story of How Many Men and Women Have Recovered from Alcoholism. Fourth Edition New York: Alcoholic Anonymous World Servives, Inc.

Black,C. (2002). It will never happen to me: Growing up with addiction as a youngster, adolescents, adults. Bainbridge Island: MAC Publishing.      

Johnson, V. (1973). I’ll quit tomorrow. New York: Harper & Row

O’Neil, J.T. & O’Neil, P. (1989). When Your Loved One Wont Quit Alcohol or Drugs. Oakland, California: New Harbinger Publications.

Books for Clinicians

Beck, A.T., Wright, F.D, Newman, B.L (2001). Cognitive Therapy for Substance Abuse. New York: Guilford Press.

Nace, E & Tinsley, J. (2007). Patients with substance abuse disorders: Effective identification, diagnosis and treatment. New York: Norton and Company.

Smith, D & Seymour, R. (2001). A clinicians guide to substance abuse: New York: McGraw-Hill Press.

Referrals to Cognitive Therapy in Your Area

www.academyofct.org