Anxiety / Exposure

·         Fear: Real or emotional response to perceived or imminent threats. 

·       Anxiety: Anticipatory fear, the anticipation of future threats. Muscle tension in anticipation.

·       The body doesn’t differentiate between fear and anxiety.

·       The front part (prefrontal cortex) of the brain deals with memory formation.

·       Cortisol reduces the volume of the prefrontal cortex.

·       We want to help our patients with the high-road part of the brain.

·       LT memory and LT memory retrieval (hippocampus).

·       The Chimp Paradox book by S Peters (2012) simplifies all of this.

·       Emotional reasoning causes us to react in response to it.

·       The stomach slows down when we have anxiety.

·       Tiredness and fatigue are particularly common if the anxiety is sustained.

·       Moderate stress or anxiety is normal, helpful, useful, and desirable.

·       It becomes an issue when it overwhelms you or becomes too strong. It may start presenting itself in unhelpful situations e.g., doing your supermarket shop.

·       This would be classified as Clinical Anxiety Disorder.

·       Panic disorder: Very important! A condition which stands alone. Any other anxiety disorder will have panic as a part of it. Panic disorder is out of the blue and more focused on physical symptoms. ‘Out of the blue’ panic attacks.

·       The word ‘attack’ takes the agency away from the patient. The word ‘episode’ can be more useful to use with a patient who has experienced a panic attack. 

 Your emotions, energy, mental state, performance, and general well-being are all affected differently by the two types of stress: eustress and distress.

·       The individual’s brain is overloaded with many concerns or worries. There can be a general theme but often they worry about everything. It soaks up a great deal of energy and often the person struggles to function. 

·       We can categorise a lot of anxiety disorders but sometimes we cannot.

·       Behavioural experiments test a thought or belief. 

·       Graded exposure: The most important behavioural technique in the treatment of anxiety disorders.

·       Habituation is key. Get the patient to repeat the processes as much as possible.          Shift away their avoidance techniques. They must stay in a situation that makes them anxious.

·       Get the individual to habituate to their fear.

·       Compile a list of all the things they are afraid of, grading them from easiest to most difficult.

·       Maintaining Processes: Commit this to memory.

·       This is from the Clarke article on Anxiety Disorders and why they persist.

Avoidance behaviours:

·       Some are very easy to see and understand but there can be covert or hidden behaviours, which the patients themselves may not fully recognise.

Attentional Deployment

·       The person may look for the threat cue.

·       Social anxiety: They keep their head down, and don’t maintain eye contact. This usually draws attention instead.

Spontaneous Imagery

·        Common in anxiety disorders.

·       In their mind’s eye, they’ll see people laughing at them and they’ll react in concert with this.

Emotional Reasoning

·       I feel the emotion, therefore, everyone must see the emotion. E.g., sweating that the person can feel. They assume people will see them as being drenched in sweat when this probably isn’t the case.

Memory Processes

·       The person can remember the emotion but not the detail associated with the emotion. The person is looking for memories, which confirm what they feel no matter how poor the information is. Provided it supports their narrative, they will act in concert with this.

·       Culture has an impact.

·       Some anxiety disorders are specific to certain countries or geographical locations.

·       We should not approach everything from a white Western interpretation and start thinking more globally to understand other people’s cultures, religions etc. Try to understand things from the patient’s perspective.

·       Look at things broadly, so that you don’t miss something with a patient. Don’t be dismissive.

·       Three main types of graded exposure:

•       In vivo

•       in vitro 

•       Interoceptive.

·       Applied relaxation can sometimes be used as an avoidance strategy by the patient.

·       Flooding is no longer used due to ethical concerns. E.g., putting someone with a phobia of spiders in a room full of them and locking them in the room.

·       Your anxiety can only go up to a certain level but that doesn’t mean your brain won’t think that it’ll go higher. Physiologically, this isn’t possible. This is something to reiterate to the patient and reassure them.

·       Be clear with the patient that none of these things will hurt or harm you.

·       Stay with the anxiety for long enough and your feared consequence will occur (unlikely to happen) or that outcome will not happen. This establishes new learning and habituation with exposure.