five-factor (area) model for anxiety disorders: an
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Five-factor (area) model for Anxiety
Disorders: An evidence-based
pragmatic psychological treatment
Sammy Cheng, Ph.D.
Specialist in Clinical Psychology
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� Methods: Methods: Methods: Methods: 5,719 Chinese adults aged 16–75 years in Hong Kong population, using the Chinese Revised Clinical Interview Schedule
� Results: Results: Results: Results: The weighted prevalence estimate for any past-week CMD was 13.313.313.313.3 %%%%, , , , with mixed anxiety and depressive disorder being the most frequent diagnoses. Among individuals with CMD, only 26262626 %%%% had consulted mental health services in the past year; less than 10less than 10less than 10less than 10 %%%%consulted general practitioners or family physicians.
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Different types:
� Specific Phobias
� Social Phobia
� Panic Disorder
� Agoraphobia
� Generalized Anxiety Disorder (GAD)
� Obsessive-Compulsive Disorder (OCD)
� Post-Traumatic Stress Disorder (PTSD)
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Two main strands of treatment:
1. Medications (e.g. SSRIs)
2. ‘Talking Therapies’ such as Cognitive Behavioral Therapy (CBT)
The best effects are seen when medications and The best effects are seen when medications and The best effects are seen when medications and The best effects are seen when medications and CBT are combined.CBT are combined.CBT are combined.CBT are combined.
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� A mixture of cognitive and behavioral techniques
that link a person’s environment, thoughts, feelings,
behaviors and physical reactions
� Cognitive techniquesCognitive techniquesCognitive techniquesCognitive techniques: address “unhelpful” thoughts
that increase anxiety
� BehavioralBehavioralBehavioralBehavioral techniquestechniquestechniquestechniques: address “unhelpful” behaviors
that increase anxiety in the long run
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1. Focus on current problems current problems current problems current problems of relevance to
the patient;
2. Delivery built on effective relationship effective relationship effective relationship effective relationship
with practitioner;
3. Psychoeducational form of psychotherapy
for one to learn new skills of selfnew skills of selfnew skills of selfnew skills of self----
managementmanagementmanagementmanagement for everyday life practice;
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4. Clear model with strong evidencemodel with strong evidencemodel with strong evidencemodel with strong evidence
◦ Based on learning theories, anxiety disorder is
learnt and can be unlearnt by CBTcan be unlearnt by CBTcan be unlearnt by CBTcan be unlearnt by CBT
◦ Findings of neuroimaging give strong evidence
of neuroneuroneuroneuro----biological changes after CBTbiological changes after CBTbiological changes after CBTbiological changes after CBT
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Neurobiological Changes Associated with CBT J Neuropsychiatry Clin Neurosci 21:2, Spring 2009
Anxiety
Disorder
Neuro-
imaging Neuroimaging Findings after CBT
Spider phobia fMRIReduced activation of dorsolateral prefrontal cortex and parahippocampal
gyrus regions.
Spider phobia fMRIAbsence of activation of the anterior ventral insula and no difference from the
healthy control subjects
Social phobia PETReduced activities at right temporal lobe regions, amygdala, hippocampus,
rhinal activity, periamygdaloid
PTSD fMRI
Increased activation of left posterior, anterior medial temporal gyrus and
posterior cingulate gyrus activation of the posterior cingulate, medial frontal
gyrus, posterior cingulate activation, medial frontal gyrus, and left posterior
medial temporal gyrus
OCD PET Decreased activation of right caudate nucleus
OCD PET Decreased activation of right and left caudate nucleus
OCD PET Decrease in the activation of the frontal orbital cortex.
OCD fMRI Decreased activation in frontal orbital cortex.
Panic PET Decreased activation in left prefrontal, in right temporoparietal and occipital
regions.
Panic PETDecreased metabolism at right hippocampus, left ventral anterior cingulate
cortex, decrease in metabolism at right hippocampus, left ventral anterior
cingulate cortex, uvula, and pyramid of the left cerebellum and pons
CBT (ERP) reduces over-activity of frontal orbital and caudate nucleus regions in OCD patients
Orbital frontal
and right orbital frontal
Neuro-cognitive activities
in orbital frontal cortex
increased with
•Excessive swearing
•Hypersexuality
•Poor social interaction
•Pathological gambling
•Drug & alcohol abuse
•Poor empathy
•Frontatemporal dementia
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OCD: OCD: OCD: OCD: learnlearnlearnlearn the fearthe fearthe fearthe fear
� Association between neutral stimuli/ thought/ situation & anxiety responses (C.C.)
� Reduce distress by ritualizing or avoidance: +ve & -ve reinforcement (Op.C.)
� Neurobiological deficits: hyperactivity in caudate nucleus, orbitofrontalcortex, cingulate gyrus
CBT (ERP): CBT (ERP): CBT (ERP): CBT (ERP): unlearn the fearunlearn the fearunlearn the fearunlearn the fear
� Exposure: habituate fearful stimuli with decrease in anxiety or distress; extinction (C.C.)
� Response prevention(extinction, Op.C.) �fear reduction
� Reduced hyperactivity in caudate nucleus,orbitofrontal cortex, cingulate gyrus
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Significant time ××××
Treatment interactions were found in amygdalawith decreases both in brain structure (gray matter volume) and function (blood–oxygen level dependent, BOLD) responsivityafter CBT.
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Rationale:Rationale:Rationale:Rationale:
� Evidence-based psychological interventions (Cognitive Behavioral Therapy, CBT) (Cognitive Behavioral Therapy, CBT) (Cognitive Behavioral Therapy, CBT) (Cognitive Behavioral Therapy, CBT) can be effective treatments for anxiety disorders. They are recommended first-line treatments in preference to pharmacological treatment. Healthcare professionals should usually offer or refer for the least intrusive, most effective intervention first, in line with the stepped-care approach set out in the NICE guidance.
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1.1.1.1. Few experienced specialists Few experienced specialists Few experienced specialists Few experienced specialists for CBT services
2.2.2.2. Complicated models and jargons Complicated models and jargons Complicated models and jargons Complicated models and jargons for specific
anxiety disorders limit an efficient delivery of
training to clinicians and treatment to patients
3.3.3.3. Jargons: Jargons: Jargons: Jargons: negative automatic thoughts, schemata,
dysfunctional assumptions, faulty information
processing, dichotomous thinking, selective
abstraction, magnification, minimization and
arbitrary inference
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� Complicated Complicated Complicated Complicated models models models models for specific anxiety disorders
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1. Situation
2. Thoughts
3. Behaviors
4. Feeling
5. Physical reaction
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Negative
Catastrophic results
Dangerous
Avoidance behaviors
Safety behaviors
Fear
Anxious
Depressed
Heart pounding
Feeling hot
Sweaty, Shakiness
Headache, Stomach pain
Nausea
Situation
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Thoughts
Feeling
Behaviors
Physical
reaction
5-factor model for
Anxiety Disorder
Reduce
unhelpful
thinking
Slow down
physical
reaction
Reduce
unhelpful
behaviors
My car will fall from
bridge. I am going to
die
Stop the car away
Drive another way next time
Fear
AnxiousHeart pounding
Feeling hot
Sweaty, Shakiness
Headache, Stomach pain
Nausea
Situation
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Thoughts
Feeling
Behaviors
Physical reaction
Drive near a bridge5-factor model for
Agoraphobia
Cognitive
restructuring
Exposure exercise
Behavioral experiments
Calm
breathing
I have the heart
attack and going to
die
Try to escape and leave the
market. Call for help
Go to AED
Intense fear
AnxiousHeart pounding
SOB, faint
Situation
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Thoughts
Feeling
Behaviors
Physical reaction
In a crowded market5-factor model for
Panic disorder
Cognitive
restructuring
Interoceptive exposure
Behavioral experiments
Calm
breathing
I am contaminated
and must wash the
hands
Wash hands repeatedly
Put of glove
Ask family to clean dirt
Distressed
AnxiousSweating
Muscle tension
SOB
Situation
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Thoughts
Feeling
Behaviors
Physical reaction
Touch dirt on floor5-factor model for
OCD
Cognitive
restructuring
Exposure with response
prevention
Calm
breathing
I will embarrass myself.
I don’t know what to say.
I look stupid in front of
others
Avoid social contact
Self absorb and conscious
Remain mute in interactions
Leave the scenario
Tense, worried
AnxiousBlushing
Sweating
Muscle tension
SOB
Situation
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Thoughts
Feeling
Behaviors
Physical reaction
Meet a stranger in work5-factor model for
Social Phobia
Cognitive
restructuring
Assertiveness training
Modeling
Behavioral experiment
Calm
breathing
I will be hit by car again
The car is rushing to me
The driver ruined my life
Cross road with others
Avoid to leave home
Drinking to numb self
Terrified
Fearful
Anxious
Angry
Trembling
Poor sleep
Sweating
Muscle tension
SOB
Situation
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Thoughts
Feeling
Behaviors
Physical
reaction
Walking near the road5-factor model for
PTSD
Cognitive
restructuring
Exposure exercise
EMDR
Calm
breathing
I can cause my many big
troubles
I cannot manage it
Mentally ruminate the
problems (worrying)
Fearful
Anxious
Depressed
Trembling
Poor sleep
Muscle tension
SOB
Situation
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Thoughts
Feeling
Behaviors
Physical
reaction
Minor problem in workplace5-factor model for
GAD
Cognitive restructuring
Detached mindfulness
Postponement of worry
Distraction
Muscle
relaxation
Cognitive
Psychoeducation
Identify –ve thoughts
Thought diary
Modify –ve thoughts
Behavioral
Distraction
Breathing control
Behavior experiment
Exposure (in vivo)
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Cognitive
Self-talk statement
Worry time log
Mindfulness
Problem solving
Behavioral
Cued relaxation
Imagery exposure
Activity schedule
Role play/
modeling
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� Integrate patient’s information into 5-factor
model
� Associations among –ve thoughts, avoidance,
affect, physical responses
� Normalize
� Intro tx strategies:
◦ Cognitive restructuring
◦ Exposure (gradual facing)
◦ Symptom management
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� Explain role of -ve thoughts on behaviors,
affect & physical reaction
� Negative thoughts may not be 100% valid
and can be modified
� Elicit negative thoughts via patient’s
examples
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� What is the evidence for the thought?
� Is there a cognitive error?
� Is there an alternative explanation?
� What is the benefit for that thoughts?
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� Use of rational thoughts for substitute the
negative one
� Repeat and say aloud the rational thoughts
� Write down these self-talk statements
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1. Set the hierarchy of feared situation with
introduction of Subjective Unit of Distress
2. List the avoidance and safety behaviors
3. Gradual exposure to the feared situation
with experience of habituation
4. Modeling and role play the exposure
5. Imagery or in vivo exposure practiced
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� Diaphragmatic breathing: involves taking
smooth, slow, and regular breaths
� How to do it?
1. Take a slow breath in through the nose,
breathing into your lower belly (~ 4 seconds)
2. Hold breath for 1 or 2 seconds
3. Exhale slowly through the mouth (~ 4 seconds)
4. Wait a few seconds before taking another
breath
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� http://www.drsammycheng.com/
� https://www.facebook.com/drsammycheng/
� http://apt.rcpsych.org/content/aptrcpsych/8
/3/172.full.pdf
� http://www.ascbt.com/cbt-explained
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