Evaluation of Anxiety

Some panic attacks are preceded by period of heightened anxiety, others may appear to come out of
the blue. It is assumed that in both cases the crucial event is a misinterpretation of bodily sensations.
Suddenly getting up from a sitting position, a different emotional state, exercising, drinking coffee
might be triggers. Absence of identifiable triggers may be interpreted as evidence that there is a
physical cause of anxiety.

Assessment-

Brief description of presenting problems:

1. Description of a recent occasion when problem occurred/was at its most marked

a. Situation
b. Bodily reaction
c. Cognition
d. Behavior
2. List of situations in which problem is most likely to occur and is most severe
3. Avoidance -situation/activities, active/passive
4. Modulators – things making it worse or better
5. Attitudes and behaviors or others
6. Beliefs about causes of problems
7. Behavioral experiment
8. Onset and course

Monitor progress

 Number of sessions- between 5-20

 Style of therapy – collaborative empiricism
 Although therapist can see irrationality of the patient’s thoughts, they should not lecture
them about the validity of a positive alternative to their thoughts

STEPS

Identifying negative thoughts

Negative automatic thoughts are so habitual that they are difficult to be noticed, visual imagery also
play crucial role in anxiety. Avoidance patterns might interfere with the recall of thoughts which
triggered the anxiety, as the patient might start putting the avoidance behavior in action as soon as
he enters and anxiety provoking situation. Patients are also reluctant to recall and discuss exact
details of thoughts that occurred during episodes of anxiety.

1. Discussing a recent emotional experience – what went through your mind then? Did you
have an image then? When you were most anxious, what was the worst thing you though
 might happen? Help the patient see the link between specific sensations and specific
interpretations. List all sensations, then ask which thoughts go with which sensations and
discuss the possibility that the thoughts may be interpretations of the sensations.
2. Using imagery or role play to relive an emotional experience
3. Shifts in mood during a session – notice when mood changes. Ask- what went through your
mind just now?
 What went through your mind?
 What were you thinking?
 Did you have a mental picture?
 When you had that picture, how did you feel?
 Did you feel tense?
 Where did you notice the tension?
 Did you have the tension before you had the image?
 What do you make of that? You had a mental picture and then noticed tension in
your head?
4. Determining negative thoughts and associated behaviors – you are not quite sure what was
going through your mind when you felt anxious in (situation). Looking back at the situation
now, what did it mean to you?

Modifying Negative Thoughts and associated behavior

1. Rationale – present eh rationale for treatment by demonstrating the relationship between

thinking, feeling and behavior. Example- hear a sound in other room (weigh thoughts- there
is a burglar vs furniture fell), therapist not picking a call (does not want to see me vs she is
busy).
2. Giving information about anxiety – give description of symptoms of anxiety, lck of
relationship between anxiety and insanity, and that autonomic changes that occur in anxiety
are not dangerous. The patient can be told that a series of apparently unconnected
difficulties – such as insomnia, difficulty in making decisions, easy fatiguability, blurred
vision, problems in concentration are all aspects of an anxiety state. Clear misconceptions
about anxiety.
3. Distraction – for immediate symptom management. Train the patient to have control over
their anxiety. Later in therapy it is good to manage symptoms where it is difficult to
challenge automatic thoughts (for example while talking to someone). As an experiment, ask
the client to engage in some distraction exercises during the session.
4. Activity schedules- record hour by hour activities, rate them (0-100) for salient features such
as anxiety, fatigue, pleasure and mastery. Can help in identifying need for time
management.
5. Verbal challenging of automatic thoughts – in the session, client and therapist work
collaboratively to identify rational responses to automatic thoughts. Between sessions,
client tries to put them into practice. Use Daily Record of Dysfunctional Thoughts. In cases
panic attacks are the main problem; use panic diary.

Date Situation Emotions Automatic Rational Outcome Further

Thought Response Action
Questions which are useful for examining and testing the reality of negative automatic thoughts are:

1) What evidence do I have for this thought? Is there any alternative way of looking at the
situation? Is there any alternative explanation?
2) How would someone else think about the situation?
3) Are your judgements based on how you felt rather than what you did?
4) Are you setting yourself an unrealistic or unobtainable standard?
5) Are you forgetting relevant facts or over-focusing on irrelevant facts?
6) Are you thinking in all or none terms?
7) Am I over-estimating how responsible I am for the way things work out? Am I overestimating
how much control I have over how things work out? (use pie chart)
8) What if it happened? What would be so bad about that?
9) How will things be in X months/ years time?
10) Are you over-estimating how likely an event is?
11) Are you underestimating what you can do to deal with the situation/problem?

Introduce cognitive distortions. Help the client identify possible distortions in each thought. Replace
with a rational/effective thought. Practice.