Treating Panic Disorder with Agoraphobia:
Efficacy of Cognitive Behavioral Therapy and Other Treatment Approaches
Anthony J. Centore

Abstract
The following research investigates various contemporary treatments for panic disorder with agoraphobia, particular attention given to Cognitive-Behavioral Therapy (CBT) and drug treatments. Findings indicate both CBT and drug treatments are effective and useful in treating Panic disorder with agoraphobia. Additionally, spiritual issues are addressed and recommendations for further study are provided.

Treating Panic Disorder with Agoraphobia:
Efficacy of Cognitive Behavioral Therapy and Other Treatment Approaches

Anxiety is normal, and anthropologically designed as an instinctual human response to danger situations (Dugue & Neugroschl, 2002). In developed civilizations, anxiety is a common (and suitably adaptive) response to life stressors such as receiving bad news, relational tribulations, monetary debt, and medical illness.

Concurrently, an individual’s tolerance to—and ability to cope with—anxiety and worry depends on both life experience and personality (Dugue & Neugroschl, 2002). It is only when worry presents itself in pathological levels that it becomes maladaptive, and a diagnosis of anxiety disorder appropriate. However, in modern society excessive and maladaptive anxiety has become common plague (Hart, 1999; Short & Kitchner, 2002).

In discussing this, Archibald Hart (1999) states:
It is unlikely you can ever escape totally from this high-stress world…without forfeiting the opportunity to achieve anything meaningful with your life…How else can you achieve the American dream? Success demands that you pay the price of committing yourself to pursuing excellence. I wouldn’t really want to live any other way. But this approach to life has its penalties and pitfalls (p. 3).
Anxiety disorders affect more than 19 million American adults, and 25% of the general population. The most common, generalized anxiety disorder (GAD) and panic disorder (PD) (sometimes referred to as panic attack disorder), can greatly affect the quality of life for its sufferers (Short & Kitchner, 2002). Reportedly, 10-20% of those suffering from PD present agoraphobic symptoms in conjunction (Dugue & Neugroschl, 2002).

Panic Attack Defined

A panic attack is an explicit period of extreme discomfort or fear where at least four of the following criteria develop abruptly and peak within 10 minutes time: Palpitations (or excited heart rate), sweating, trembling or shaking, shortness of breath or smothered sensations, sensations of choking, chest pain or discomfort, nausea or abdominal discomfort, faintness, dizziness, unsteadiness, lightheadedness, feelings of unreality or detachment from reality (depersonalization), fear of losing control or “going crazy,” fear of death, numbness or tingling sensations, hot or cold flashes (DSM-IV, 2000, p. 432).

Though a significant psychological problem and physiological phenomenon, a panic attack alone is not a codeable diagnostic disorder. Panic disorder is not the occurrence of a panic attack but rather a condition that involves the presence of unexpected, recurrent panic attacks (usually with no known catalyst reported) (Barlow & Craske, 2001). Also, for an individual to qualify for PD diagnosis, he/she must present—following an attack—a minimum one month of concern/anxiety about enduring additional attacks; fear of the consequences of an attack such as losing control, dying, or “going crazy;” and a significant alteration of usual behavior, which is related to previous attacks (DSM-IV, 2000, p. 433). Furthermore, attacks cannot be due directly to drugs or physiology (i.e. cocaine, hyperthyroidism), and attacks are not better accounted for by another diagnosis (i.e. social phobia, obsessive compulsive disorder, separation anxiety) (DSM-IV, p. 440).

Agoraphobia Defined

Agoraphobia, which often accompanies PD (called panic disorder with agoraphobia) involves anxiety about being in places or situations from which escape might be difficult (or embarrassing), or where one could possibly suffer a panic attack (Barlow & Craske, 2001). These anxiety provoking situations often include crowds, busses or cars, bridges, trains, and places outside the home. These situations are avoided, or endured with noticeable distress, and often anxiety about having a panic attack (DSM-IV, 2000).

It is notable that if such avoidance is limited to a few situations; it is likely better accounted for as a phobia, rather than agoraphobia. Also, if limited to only social situations, a diagnosis of social phobia is preferred (Leahy & Holland, 2000). In addition, like a panic attack agoraphobia is not a codable disorder with the Diagnostic and Statistical Manual for Mental Disorders IV (DSM IV). Instead, agoraphobia is diagnosed as an adjunct to a present panic disorder, titled Panic Disorder with Agoraphobia (DSM IV, 2000).

One research team warns that the conditions of PD are disabling in nature by themselves, and are complicated by other psychiatric conditions, delayed treatment, and the presence of agoraphobia—which is a negative prognostic indicator (Andrews, Oakley-Browne, Castle, Judd & Baillie, 2003).
Misdiagnosis

One of the criteria, listed above, for the diagnosis of PD is that the panic attacks cannot be accounted for by either drug inducement or a prevailing medical/physiological issue, for panic attacks under the DSM IV diagnosis of PD are physiologically present due to primarily psychological provocation (Barlow & Craske, 2001). For example, 25% of persons who visit an emergency room presenting chest pain and symptoms of a pulmonary embolism are actually suffering from PD (Lee, Dade, 2003).

A practitioner, during the diagnostic interview of a client is responsible for ruling out likely medical causes of panic attacks. Hence, an in depth interview is the first step in establishing a diagnostic profile for a client suspected of having PD. Notably, recommended by Barlow & Craske (2001) the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) is a useful tool in the clinical interview process and assesses anxiety, mood & somatoform disorders, and screens for possible psychotic and drug conditions.

Among the present medical conditions and drugs/medications that can facilitate a panic attack like experience are caffeine or amphetamine intoxication, thyroid conditions, drug withdrawal, and Pheochromocytoma (a rare adrenal gland tumor). Conditions known to exasperate PD like symptoms include Mitral Valve Prolapse, which induces heart palpitations; Asthma, for it induces shortness of breath (as do allergies); and hypoglycemia has been known to create feeling of weakness or dizziness, both common with panic attacks/PD (Leahy & Holland, 2000).

Hypothesis

Evidence-based treatments for PD and panic disorder with agoraphobia are now clear (Andrews, et al., 2003). In regards, one researcher writes:

Choice of therapy will depend on the skill of the therapist in applying psychological treatments as well as the preferences of the patient, but there is a role for both psychological and evidence-based pharmacological approaches (Andrews et al., 2003).

There are numerous methods in treating PD. One effective scheme is CBT which boats an efficacy rate in PD treatment that deems it one of the great successes of psychotherapy (Barlow & Craske, 2001).
This paper will look at methods for treating PD and panic disorder with agoraphobia, and in particular will compare how CBT rates in effectiveness to other therapies, including medical treatments. It is hypothesized that though medical treatments are effective, CBT alone proves more effective than medication alone, as a treatment. It is also hypothesized that varied medical treatments will differ in effectiveness and treatment outcome. The null hypothesis of this study is that there is no difference in efficacy between the treatments under investigation.

CBT Treatment

Miler (2003) declares that practitioners should not forget about psychotherapy when treating panic anxiety, and that though the American Psychiatric Association (APA) guidelines may rate SSRIs highest, CBT has proved as effective as medication for many persons, and other (non-CBT) methods of psychotherapy have a place as well in PD treatment. Furthermore, Miller continues that there is no therapeutic substitute for patient social support, education about anxiety symptoms, reaction managing (to anxiety provoking stimuli), addressing life circumstances, and resolving emotional conflicts that may contribute to panic anxiety.

In additional support of CBT treatment, when Andrews (2003) added together the medication cost and the cost of a psychiatrists’ time to diagnose and treat a PD patient over the period of 12 months, and compared accrued fees to CBT cost, despite common economic belief after one year the cost of CBT was reported to be less than the cost of the average drug therapy. Specifically, CBT becomes more affordable than paroxetine at eight months, clomipramine at 11 months, and cheaper than imipramine at 13 months. Additionly, during the second and subsequent years thereafter, the superiority of CBT was found to increase (both economically and functionally) whether or not drug treatment continued; for if drug treatment and CBT were continued costs differences continued to augment, and if both drug treatment and CBT treatment were discontinued, patients who had undergone drug treatment relapsed in approximately 50% of instances (relapse after one year CBT treatment was non-significant until after five years post treatment) (Andrews et al., 2003). Stated in summary (also see appendix):
Cognitive behaviour therapy is both more effective and cheaper than pharmacotherapy. Tricycliclic antidepressants and SSRIs are equal in efficacy and both are to be preferred to benzodiazepines. Treatment choice depends on the skill of the therapist and the wishes of the patient. Cognitive behaviour therapy is preferred but SSRIs are commonly used; however, effective drug treatment should include behavioural treatment to limit avoidance (Andrews et al., 2003).

Rationale

Looking to the social causes for anxiety (though PD is mainly facilitated by anxiety dealing with internal physiological symptoms), psychotherapy can help patients to work through anxiety provoking psychosocial concerns—which can contribute to PD—such as family issues, money problems, and legitimate medical handicaps (Dugue & Neugroschl, 2002). The objective of CBT is to help the patient identify thoughts that are causing distress, and replacing those maladaptive thoughts with such that produce more favorable results (Dugue & Neugroschl, 2002).

The success of CBT on PD and panic disorder with agoraphobia, considered one of psychotherapies greatest achievements, boasts that 80-100% of clients in CBT treatment for PD will be without panic at the end of treatment (Barlow & Craske, 2001). These results are still existent during a two year follow-up, a dramatically higher rate than effective medications. Moreover, 50-80% of these clients are “cured” in that they present no symptomatology (and many of the remaining have only residual symptoms) (Barlow & Craske).

Negatively, as many as 50% of clients do retain substantial symptomatology post CBT
treatment, especially those with agoraphobic issues. Also, though many clients conclude treatment with 15-20 sessions, some clients necessitate significantly longer periods of CBT before meaningful real life (in vivo) improvement occurs (Barlow & Craske, 2001).

Basic Concepts of CBT

Cognitive restructuring is a major tenet of CBT, and involves replacing a thought held by
a client that is harmful, with a thought that is beneficial to the client’s psychological health. Much negative cognition is considered “automatic:” that is, the client has this thought automatically in response to a stimulus and often is unaware he/she even possesses such an cognition (Burns, 1999). This idea is dealt with by all cognitive theorists including Ellis (2003), in his discussion of irrational beliefs, Backus (2000) in his discussion of misbeliefs, and Beck (1979) in his discussion of illogical beliefs. Burns speaks about such cognitions and has labeled them by the harmful fallacies they hold such as “all or nothing thinking,” “fortune-telling,” “discounting the positive,” and “labeling” to name a few (p. 84, 99).

Breathing retraining has become a central component early in treatment for panic intervention because of the high instance of PD patients who report hyperventilatory symptoms (Barlow & Craske, 2001; Taylor, 2001). Notably however, less than 50% of PD patients show a reductions in blood levels of carbon dioxide insisting with PD hyperventilation might best be viewed as a stress-induce symptom that instigates fear, as opposed to a somatic issue (Barlow & Craske).

With this dimension in mind, though numerous studies suggest breathing retraining interventions to be effective in reducing panic attack frequency, concerns about its use have been raised (Taylor, 2001). According to Taylor, recent research suggests that since true biologically identifiable hyperventilation plays a limited role in producing panic attacks, breathing retraining may be counterproductive to treatment. In essence, attention to breathing retraining could prevent patients from learning about the true cause of their panic anxiety, which are unfounded catastrophic beliefs. There is a current warning to mental health practitioners that though breathing retraining may appear useful, clinicians must exercise care to ensure it is not misused by patients as a means of avoiding feared sensations.
Additional techniques include applied relaxation, to assist patients in preparing for, and coping with, stress inducing situations; interoceptive exposure, which is implemented to reduce the fear of one’s specific bodily cues (i.e. heart palpitations are harmless, and are not heart attacks); and in vivo exposure, which is presenting a client with a fear or anxiety provoking situation as a means of teaching the client the true powerlessness of the dreaded situation. If agoraphobia is present the goal includes the elimination of avoidant behaviors—to disconfirm and re-evaluate unhelpful appraisals (Short, 2002).

New CBT Methodology

In exposure therapy, the client is made to relax and imagine a stress inducing scenario (see above). With hope of improving this protocol, the idea of using virtual reality and home computer technology for the treatment of psychological disorders appeared first in the November of 1992 with the Human-Computer Interaction Group of Clark Atlanta University (Alcaniz, Botella, Ban, Perpina, Rey, Lozano, Guillen, Antonio, 2003).

In the investigation of the efficacy of new technology in CBT treatment, one study attempted the use of virtual reality equipment to increase effectiveness of exposures (Dong, Jang, Jeong, Shin, Choi, Kim, 2000). Although, possibly due to technological insufficiencies, the process proved cumbersome and ineffective (Dong et al., 2000). In contradiction, one meta study found patients had a significantly reduced amount of agoraphobic symptomology after using virtual reality equipment in the simulation of a fear provoking scenarios (such as an elevator ride) (Wiederhold & Wiederhold, 2003). Alcaniz et al (2003) found the use of virtual reality equipment, and home personal computer technology effective in the treatment of panic anxiety. The use of the internet has also been found useful for specific treatment of PD (Alcaniz et al., 2003; Richards & Alvareng, 2002), as has the implementation of CBT treatment of panic disorder with agoraphobia over video teleconference (Bouchard, Payeur, Rivard, Allard, Paquin, Ranaud, Goyer, 2000). This research shows some promise for further evolution of effective CBT treatment methods.

If CBT is Not Working

If there is an inadequate response after an adequate trial of CBT treatment, it may be wise to switch to another evidence-based treatment (Andrews, Oakley-Brown, Castle, Judd, Baillie, 2003). Andrews also notes, if PD is more severe than other co-occurring conditions (determined by impairment of daily living, and distress from symptoms), panic should be the initial focus of treatment, regardless of chronological onset. Also, while the presence of agoraphobia leads to a more negative prognosis; common co-morbid depression has no significant effect on outcome.

Medical Treatments

Antidepressants offer the most effective pharmacologic intervention for anxiety disorders (Dugue & Neugroschl, 2002). Four classes of antidepressant medication including selective serotonin reuptake inhibitors (SSRIs), high potency benzodiazepines, trycyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs) may be considered for the treatment of PD (Short & Kitchner, 2002).
Benzodiazepines vs. SSRIs

To begin, Miller (2003) remarks:
The American Psychiatric Association’s current guidelines stress the advantages of antidepressant treatment. Selective serotonin reuptake inhibitors (SSRIs) like fluoxetine
(Prozac), sertraline (Zoloft), and paroxetine (Paxil) are most popular, but other antidepressants—for example, the newer drug venlafaxine (Effexor) and the older tricyclics and monoamine oxidase inhibitors — are equally effective. And so are benzodiazepines, including, alprazolam (Xanax), lorazepam (Ativan), and clonazepam (Klonopin). The choice depends on individual circumstances and side effects.

Benzodiazepines have been effective in treating PD for over 20 years. However, with recent concerns of drug abuse, addiction, Central Nervous System (CNS) side effects (i.e. sedation), long term use of these drugs is no longer considered optimal (Brown & Harvard, 2003). In investigating the drug of preference, there is little research comparing SSRIs head-to-head with benzodiazepines, though the research that is available suggests that in most cases SSRIs will win the risk-benefit comparison to benzodiazepines, for though SSRIs do have side effects (i.e. sexual dysfunction, insomnia, and upset stomach) they lack the benzodiazepines freqency physical or psychological dependence (Miller, 2003). Short & Kitchner (2002) elaborate stating that emerging clinical data suggests SSRIs to be the current first line of treatment, with paroxitine and sertraline being the most favorable of the SSRI group.
Contrarily, one study by Brown & Harvard University (2003) found that from 1991-2001 SSRI only prescriptions for PD increased from four to 11.2%, while benzodiazepine only treatment declined from 54.5 to 36.2%. This, showing a definite recent sway from benzodiazepine use to SSRI prescription, also displays that benzodiazepine only prescription is still considerably higher that SSRI, for PD treatment.

Miller (2003), in review of a Harvard & Brown anxiety research project involving the treatment of over 400 New Englanders, describes the use of SSRIs as “surprisingly low,” especially for patients who didn’t have symptoms of depression as well as anxiety. Miller continues to write that benzodiazepines are still the drugs most commonly used to treat PD and that even for panic patients with substance abuse problems, physicians prescribed benzodiazepines more often than SSRIs.

SSRIs have been around now for almost 15 years and have become the treatment of choice for some anxiety disorders, like obsessive-compulsive disorder (Miller 2003). However, due to the almost immediate relief benzodiazepines produce, compared to the several week delay with SSRIs, with PD patients benzodiazepines are greatly preferred. In addition, many patients find benzodiazepines more tolerable than SSRIs for while 50% of PD suffers discontinue SSRI use due to side effects, less than 10% discontinue benzodiazepines. Lastly, miller states concern over chemical dependence with benzodiazepines may be exaggerated for vast majority of persons with PD who are prescribed benzodiazepines do not after time necessitate higher doses, nor do they take the drugs for recreational purposes. This is a direct contradiction to research of benzodiazepines such as Clonazepam; brand name Klonopin (Physicians Desk Reference, 2002, p. 93). Explicitly, “Concern about physical or psychological dependence is reasonable but should not be exaggerated” (Miller).
To reap the benefits of both medications, Miller (2003) suggests a practitioner could prescribe both a benzodiazepine and an antidepressant at the onset of treatment. After suitable time has passed for the SSRI to take effect, the benzodiazepine can be gradually withdrawn. In this way, a PD patient receives the immediate benefits of a benzodiazepine, and the long term safety of an SSRI.

TCA vs SSRI

Due to side effect and tolerability concerns, SSRIs are often preferable to tricyclic andtidepressant medications which produce anti-cholinergic and cardiovascular effects (Dugue & Neugroschl, 2002). The objective of a recent study was to compare the short-term efficacy of SSRIs against TCAs in the treatment of PD. For this a meta-analysis was conducted that concluded there were no differences between SSRIs and TCAs on any of the effect sizes (drug effectiveness), indicating that both groups of antidepressants are equally effective in reducing panic symptoms, agoraphobic avoidance, depressive symptomatology and general anxiety. Moreover the percentage of patients free of panic attacks at post-test did not differ (Bakker, Balkom, Spinhoven, 2002).

Medication choice was not found to be equal however, for the number of patient drop-out was significantly lower in the group of patients treated with SSRI medications (18%) as opposed to patients treated with TCAs (31%). In summary, SSRIs and TCAs were found to be equal in efficacy for the treatment of PD, but SSRIs are more tolerable (Bakker et al., 2002).
HCL Medications

First, it must be explained that not all HCL treatments for PD are equal. The results of one randomized, double-blind, 15-week study with 225 patients who were treated with either sertraline HCl or paroxetine HCl—for PD—demonstrated comparable alleviation of symptoms during the 12-week treatment phase. However, during the following 3-weeks during dose tapering, the efficacy of sertraline HCl was maintained whereas participants administered paroxetine HCl demonstrated significant relapse and a greater number of withdrawal symptoms when compared to sertraline HCl. The most common side effects included upset stomach/diarrhea, insomnia, drowsiness, dry mouth, sexual side effects, tremors, sweating, feelings of agitation, and loss of appetite. Explained, “These findings suggest that patients taking sertraline HCl will maintain response, while patients on paroxetine HCl will have more panic attacks and show overall worsening during the dose tapering and discontinuation process” (Bandelow, 2003).

Experience of Psychiatrist

There is a considerable amount of research that considers the possibility that psychotherapist characteristics may influence the outcome of treatment. Not surprisingly,
therapist variables that may affect psychotherapy outcome include warmth, and supportiveness—though neither age, ethnicity, nor gender affect significantly therapy outcome (Gorman, Martinez, Goetz, Huppert, Ray, Barlow, Shear, Woods, 2003). This has held consistent with CBT treatment for PD and Panic Disorder with Agoraphobia.

Contrarily, much less research has been conducted considering psychiatrist expertise effect on the outcome of pharmacotherapy. In regards to practitioner experience, age, and gender with psychopharmacological treatments of the anti panic drug imipramine, one study’s results show that greater years of experience held by a psychiatrist was a significant predictor of better outcome with imipramine drug treatment (while psychiatrist age and gender were less relevant) (Gorman et al., 2003).

Japanese Herbal & Alternative Medications

According to one study, Japanese herbal supplements, known as Kampo medicines have been used to treat patients with psychological disorders since ancient times (Mantani, Hisanaga, Kogure, Toshiaki, Shmada, Terasawa, 2002).

More contemporarily, there has been a spawned interest in ancient, herbal, and alternative medications. One recent study investigates four case studies of individuals suffering from panic disorder with agoraphobia, and their success with Kampo medication treatment.
Reportedly, the Kampo medicine—Kami-shoyo-san (TJ-24)—relieved panic attacks, anticipatory anxiety and agoraphobia in two of the patients researched, and Kampo medicine Hange-koboku-to (TJ-16) relieved these symptoms in the other two patients (Mantani et al., 2002). The patients in whom Kami-shoyo-san was effective were older (59 & 53 as compared to 33 & 45) and complained of more symptoms than those in whom Hange-koboku-to was effective (Mantani et al).

Though this and other studies suggest Kampo medicines and other alternative herbal remedies may be useful as additional or alternative treatments for PD, patients should be warned of the risks of taking herbal, non-federally governed substances. More specifically, herbal supplements are not regulated by the food and drug administration, and are often sold without appropriate concern of safety, dosage, side effects, and drug interactions. Though herbal supplements can be effective, they can also be effectively destructive (Hart, 2003).

Spiritual Issues

No one is as well versed regarding the topic of spiritual issues in panic disorder as Dr. Archibald Hart of Fuller Theological Seminary. In one of his many texts, Hart (1999) addresses a scenario he has seen many times with Christian individuals who suffer from PD.

As a prelude to the vignette, a client named Susan has suffered from anxiety her entire life. This condition persisted until college when Susan became a Christian. Accordingly, she learned to pray, study scripture, and for the first time in her life experienced a hiatus in anxiety for she found much hope and reassurance in these spiritual disciplines.

However, one day Susan awakes to find her new sense of peace has left and that her feelings of anxiety have returned, intensified (Hart, 1999). She seeks therapy asking the questions, “what happened?” and “had God deserted me?” Hart responds:
Susan’s experience is a common one. Conversion often brings a wonderful sense of comfort and release from anxiety. It is the honeymoon phase of faith, and new believers often experience great excitement over a newfound prayer life and fresh insights from scripture. God’s Spirit seems very close and His comfort very real, which they are.

But anxiety can become deeply routed in our personalities, and while God sometimes provides a miraculous removal of these routes, more often He calls upon us to begin and then continue the process of sanctification…(p. 53).

Hart (1999) first assures the client that God has not deserted her. After that he discusses how healthy faith can foster protection from panic anxiety (p. 256), often using stories of Christ’s balanced life (p. 257). According to Hart, spirituality can both increase an individual’s anxiety, and alleviate it.
Other Christian practitioners have also considered issues of spirituality in psychological disorders (often with varying conclusions). For example, McMinn (1996) would entertain the possibility of spiritual sin being a cause of PD, while Adams (1970) believes all psychological disorders to be partly manifested due to the spiritual sin of the client.

Discussion

This document has investigated the issues of PD, and panic disorder with agoraphobia. Specifically, the ailments were defined, suggestions and warnings were given for the diagnosis of these disorders, as well as an investigation of several treatments for PD and panic disorder with agoraphobia.
According to the American Psychiatric Association, medical treatments are first in que, before CBT treatments, though the studies that compared medical treatments against CBT provided results that suggest CBT to be equally effective to medications during treatment, less expensive than chemical treatments after one year of treatment, and CBT was found to have better result (less relapse) than chemical treatments, whose results seems to dissipate quickly after the withdrawal of the medication (Andrews et al., 2003). This supports the hypothesis of this study.

However, the null hypothesis could not be rejected in regards to the comparative analysis of effectiveness of differing chemical interventions for PD, for all the medication investigated in this study were very effective for the treatment of PD and equally effective for the treatment of panic disorder with agoraphobia (Miller, 2003). The main differences between medications dealt with compliance levels in patients and the side effects produced by different medications (Bakker, Balkony & Spinhoven, 2002).

In addition to this, for both CBT and medical treatments, unorthodox subcategories of treatment were researched, namely the use of electronic media in CBT treatment, and alternative herbal supplements in medical treatment. Both “unorthodox” treatments showed significant levels of effectiveness and are of suitable worth for further investigation (Weiderhold & Weiderhold, 2003; Mantani et al., 2002; Dong et al., 2000).

Lastly, Spiritual issues in PD and anxiety were addressed by looking at Archibald Hart’s (1999) model and insight regarding the issues of spirituality (Christian specifically) in the treatment and presentation of anxiety issues.

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Appendix

(Andrews, Oakley-Browne, Castle, Judd & Baillie, 2003).

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Most people who develop mesothelioma have worked jobs where they inhaled asbestos particles, or have been exposed to asbestos dust and fiber in other ways. While not conclusive, it has also been suggested that washing the clothes of a family member who worked with asbestos can put a person at risk for developing mesothelioma.[3]

Unlike lung cancer, there is no association between mesothelioma and smoking. However, smoking greatly increases the risk of other asbestos-induced cancers.[4]

Mesothelioma.com is a website that provides a lot of information for persons with Mesothelioma. There are many good articles on the site about the disease, treatment, and asbestos exposure. They also provide information on various types of mesothelioma. The website appears to be funded by attorneys who provide representation to individuals who have been exposed to Asbestos.

1 “Mesothelioma risks and causes : Cancer Research UK : CancerHelp UK”. Cancerhelp.org.uk. 2010-06-23. Retrieved 2010-08-20.
2 Ashrafian H, Athanasiou T, Yap J, DeSouza AC. Two-chamber intracardiac mesothelioma. Asian Cardiovasc Thorac Ann. 2005 Jun;13(2):184-6.
3 Eastbourne Today. “Woman’s death from asbestos”. Retrieved 2008-10-28.
4 Muscat JE, Wynder EL (May 1991). “Cigarette smoking, asbestos exposure, and malignant mesothelioma”. Cancer Res. 51 (9): 2263–7. PMID 2015590.

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You can read the full article, titled “Life and Health Coaching benefits for Mesothelioma and other Cancer Patients”

Here’s a brief excerpt:

Services offered by therapy practices like Thrive Boston, a Boston-area center that helps individuals overcome a variety of emotional challenges, are catching the eye of cancer patients who want to make the most of their remaining time. While the practice also offers “life coaching” for executives and others who need career assistance, the “health coaching” aspect of their business continues to grow in popularity. Health coaching can address a number of issues commonly experienced by cancer patients including depression, anxiety, stress, and even guilt.

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Criteria for Panic Attack

A panic attack is an explicit period of extreme discomfort or fear where at least four of the following criteria develop abruptly and peak within 10 minutes time

Criteria
Palpitations, or excited heart rate
Sweating
Trembling/shaking
Shortness of breath/smothered sensation
Sensations of choking
Chest discomfort or pain
Nausea or abdominal discomfort
Criteria continued
Feeling faint, dizzy, unsteady, lightheaded
Feelings of unreality or detachment from reality (depersonalization)
Fear of losing control or “going crazy”
Fear of death
Numbness or tingling sensations
Hot or cold flashes

A Panic Attack is Not a Codable Disorder
Criteria for Agoraphobia
Anxiety about being in places or situations from which escape might be difficult (or embarrassing), or in which one could possibly suffer a panic attack.
These situations often include crowds, busses, bridges, trains (&autos), and places outside the home
Note: if avoidance is limited to a few situations, it is probably a Phobia. If limited to only social situations, is probably a Social Phobia

Situations (mentioned prior) are avoided, or endured with noticeable distress, & often anxiety about having a panic attack.
Anxiety/phobic behavior not better accounted by another disorder.
Agoraphobia is Not a Codable Disorder

Diagnostic Criteria for Panic Disorder (300.01)
Unexpected, recurrent panic attacks (usually with no known catalyst reported)
Attack followed by a minimum one month of concern about having additional attacks, fear of consequences (losing control, dying, “going crazy”), a significant alteration of usual behavior related to previous attacks

Attacks not due directly to drugs or physiology (i.e. cocaine, hyperthyroidism)
Attacks not better accounted for by another diagnosis (i.e. social phobia, OCD, separation anxiety)
Panic Disorder W/Agoraphobia 300.21
Maintains same criteria as 300.01.
In addition: includes criteria for agoraphobia disorder.
The Diagnostic Interview
An in depth interview is the first step in establishing a diagnostic profile
Recommended: The Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV)
Assesses Anxiety, mood, & somatoform disorders. Screens for psychotic and drug conditions.

Do Not Diagnose!…until medical conditions are ruled out.
PD/PDA like symptoms can be facilitated by:
Caffeine or Amphetamine intoxication
Do Not Diagnose (Cont.)
Caffine/Amphetamine Intoxication
Thyroid conditions
Drug Withdrawal
Pheochromocytoma (a rare adrenal gland tumor)

ALSO, the following can EXACERBATE PD/PDA
Mitral Valve Prolapse (heart palpitations)
Asthma (shortness of breath)
Allergies (shortness f breath)
Hypoglycemia (weakness/dizziness)
Functional Analysis
Various methods of assessment such as the Clinical Interview, Standardized Inventories (the Mobility Inventory, Anxiety Sensitivity Index, etc.), and Behavioral tests will provide the material for a full functional analysis.
Functional Analysis
Panic attack topography: Sensations, frequency, duration, apprehension (how often thinking about them), and type (expected or unexpected)
Antecedents: Situational (where PA occurs), internal issues (thoughts of “the big one”)
Misappraisals: Physical (heart attack), mental (going crazy), and social (others will think…)
Functional Analysis (2)
Behavioral reactions to PA: Escape (avoiding places), help seeking, protection (body checks, drugs)
Behavioral RXNs to anticipation: Avoidance, cognitive avoidance, safety signals (carries meds, always knows where people are, etc.)
Consequences: Family, work, leisure, social
Functional Analysis (3)
Assess general mood.

Rationale for CBT treatment for PD/PDA
The success of CBT on PD/PDA is considered one of psychotherapies greatest achievements.
80-100% of clients in CBT treatment for PD/PDA will be without panic at the end of treatment.
Such results are still existent during a 2 year follow-up. A higher rate than effective medications.
Also, 50-80% of these clients are “cured” in that they have no symptomatology (and many of the remaining have only residual symptoms)
Rationale for CBT treatment for PD/PDA (Cont.)
However, as many as 50% of clients retain substantial symptomatology post-treatment. Especially those with agoraphobic issues.
Also, some clients necessitate significantly longer periods of CBT before meaningful/improved In Vivo response occurs.

Basic Components of CBT for PD/PDA

Cognitive Restructuring
Breathing Retraining: this became a central component early for panic intervention because of the high instance of PD/PDA patients who report hyperventilatory symptoms. However, less than 50% of PD patients show a reductions in carbon dioxide. Therefore, hyperventilation might best be viewed as a stress-induce symptom that instigates fear.

Applied Relaxation
Interoceptive Exposure: purpose is to reduce the fear of one’s specific bodily cues (i.e. heart palpitations are harmless, and are not heart attacks)
In Vivo Exposure

Treatment Protocol (Session 1)

Goals of Session One:

Describe anxiety: and identify patterns of anxiety and places/situations in which it occurs. Investigate briefly when first occurred.
Help patient in identifying antecedents: (situational, physical, and mental)
provide a treatment rationale & treatment description
Introduce self monitoring/homework.
Self Monitoring/Homework
Keep in mind the “three-response system:” (when you are anxious, what do you feel, think, and do?)
Log any panic attacks in the panic attack record. This is carried in the patients wallet and completed as soon as possible post-bellum any panic attack.
Self Monitoring/Homework (2)
The Daily Mood Log is used for to rate daily levels of depression, anxiety, and worry about PAs.

Session 2

Goals of this session are the following
Describe the physiology underlying anxiety and panic
The survival value and protective function of anxiety and panic (i.e. fight or flight)
The physiological basis for sensations during a panic attack (sympathetic nervous functioning)
The roll learned and cognitively directed fears and thoughts on panic sensations (panic attacks the seem to come from “out of the blue” are trigger by subtle internal cues)
Session 2 (cont.)
This information both reduces anxiety (and panic attacks) by decreasing uncertainty about panic attacks, and adds credibility/confidence to the CBT process.
Homework (Session 2)
Patients are instructed to read (and re-read) a handout on the physiological symptoms of anxiety and panic
Patients are to develop an alternative conceptual framework and an objective versus subjective self monitoring awareness
The therapist reassures clients the panic will subside as they persist in reading the material

Session 3

Primary Goal: Begin breathing control
Step one: clients asked to hyperventilate by breathing quickly and deep for 1½ minutes (to facilitate panic symptoms); after which the are instructed to sit, close their eyes and breath slowly until panic like symptoms have subsided

50-60% of clients report symptoms during the exercise emulated symptoms of a panic attack in vivo. However, because the environment is considered “safe” clients rate the experience as less anxiety provoking. This is important for the therapist to note—for it displays the significance of perceived safety on the degree of anxiety.

The client is educated on breathing, in specific misinterpretations the client might possess about the issue of “overbreathing”

The client is taught to breathe from the diaphragm, and to rely less on his/her chest muscles
Client is instructed to concentrate on breathing by counting inhalation and thinking the word “relax” as he/she exhales

Homework (Session 3)
The integration of breathing exercises and cognitive control is emphasized.

WARNING: On occasion clients mistakenly believe there are dire consequences should they fail in regulating their breathing, hence increasing anxiety and panic symptoms.
Practice abdominal breathing BID, 10 min.
Continue self-monitoring

Session 4

Goals: 1) Develop breathing control (at this point clients are instructed to practice slow breathing only in “safe” environments. Clients are discouraged to practice slow breathing in panic/anxiety situation, until they are skilled.

Goals: 2) Begin active cognitive restructuring. Steps:
Restate that there is no real threat with PA
Clients are taught their thoughts are guesses, not facts! Furthermore, clients are taught the fallacy of their downward arrow thinking (Panic->Faint->embarrassment->overwhelming shame). Clients taught to observe their automatic thinking and self statements.

Un-useful Statement/insufficient: “I feel terrible—something terrible might happen now!”
Useful for challenging misassumptions “I am afraid if I get too anxious when driving that I will drive of the side of the road and die!”
Homework: Question odds, look at evidence for thoughts. Continue monitoring.

Session 5

Session Goals: Enhanced breathing control
Fixing a second cognitive error: Catastrophizing– is where a client views a situation as dangerous, unbearable, or catastrophic.

“If I faint, people will think that I am weak; and that would be unbearable.”

“The whole evening is ruined if I start to feel anxious.”

Decatastophising: to realize the scenarios are not as bad as you first thought.
How to manage/cope with bad situations.
Teach that awfulizing physiological symptoms is to give them control.

Session 6

Goal: Begin Interoceptive Exposure (IE)
Clients are often not aware of the things they avoid to avoid the physical sensations that accompany them…
Exercise
Emotional discussions
Suspenseful movies
Steamy rooms (shower with door closed)
Certain foods
Stimulants (i.e. coffee)

The purpose of interoceptive exposure is to repeatedly induce the sensations that are feared, so that the fear response weakens.

Clients are to rate their sensation intensity 0-8
Shake head back and forth for 30 seconds
Head between legs for 30 seconds, and lifting up quickly
Running for 1 minute
Holding breath for as long as possible
Session 6 (Cont.)
Complete muscle tension for one minute
Pushup position as long as possible
Spinning in a swivel chair for 1 minute
Breathing through a straw with plugged nose
Breathing as slow as possible for 2 minutes
Staring at a mirror for 2 minutes

If these don’t work, make them worse
Take a deep breath and hold it, then hyperventilate
Wear heavy clothes in aheated room
Choke the patient with a tongue depressor, a high collared sweater, or a necktie!
Startle the client with a loud noise during relaxation!

Anxiety will often be lower in session that in vivo. Discussion can center on the misassumptions that make naturally occurring panic symptoms more frightening.

Session 7
Repeat interoceptive exposure
At this time clients are instructed to apply breathing control at times of anxiety
Cognitive restructuring continues with “hypothesis testing,” which is experimental design to disconfirm catastrophic hypotheses.

Test: will one fall if he/she does not lean on a wall while feeling dizzy? Will someone comment on how weird a client is, in public?
More induction and coping in this session.

Session 8
Continue interoceptive exposure and hypothesis testing.
Review daily, in vivo, practice of IE

Session 9
Goals: extend interoceptive exposure to natural activities (i.e. exposure to daily tasks that have been dreaded or avoided outright).
Exercise
Eating avoided foods (spicy, filling)
Saunas and steamy showers
Caffeine!

Suspenseful movies
Disneyland rides

Clients are requested to ID maladaptive cognitions and restructure prior to each activity. Remove safety signals (i.e. lucky charms, rituals, cell phones) if appropriate.

Session 10
Begin exposure to feared/avoided agoraphobic situations (in vivo)
1) Be careful to remove safety behaviors/objects.
2) An emphasis on pre-event cognitive restructuring
In Vivo exposure: targets situations in which anxiety and panic are expected to occur, and from which escape is difficult (as opposed to IE in the therapy office).

Rationale for In Vivo: Much like IE, prolonged exposure will lower the power of the feared situation. Amount of time devoted to In Vivo will be directly related to client’s agoraphobia.

In Vivo Exposure WILL FAIL if:
Haphazard designs/attempts
Exposure too brief
Exposures spaced too far apart
Conducted without confidence/sense of mastery
Conducted while maintaining catastrophising ideations.

Session 11
If possible a spouse is introduced into counseling and coached on how to support the PDA partner with daily In Vivo exposures.
Sessions 12-15
In Vivo exposures completed independently, or with a partner, over the last week are reviewed, and general principles are reinforced. Therapist feedback on cognitive restructuring and partner’s coaching technique are provided, if necessary.

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Question: Is it Social Phobia
or Social Anxiety D/O?

DSM-IV-TR Definition of Social Phobia
“A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing” (see diagnostic criteria, p. 456).

“Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack.”
“The person recognizes that the fear is excessive or unreasonable.”
“The feared social or performance situations are avoided or else are endured with intense anxiety or distress.”

“The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.”

“The fear or avoidance is not due to the direct physiological effects of a substance or a general medical condition and is not better accounted for by another mental disorder.”

Classifications of Social Phobia
Generalized (undifferentiated): when fears include most social situations.
Differential Dx: Avoidant Personality D/O
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Specific (differentiated): when fears pertain to particular social situations (e.g., public speaking).

Differential Dx: Simple Phobias
Animal Natural Environment
Blood/Injection/Injury Situational

Social Anxiety Institute’sDefinition of Social Anxiety D/O

“The fear of social situations and the interaction with other people that can automatically bring on feelings of self-consciousness, judgment, evaluation, and inferiority. The fear and anxiety of being judged and evaluated negatively by other people, leading to feelings of inadequacy, embarrassment, humiliation, and depression” (T. Richards, PhD, Med Dir)

Why Social Anxiety D/O?
Misunderstanding of term “social phobia.”
Misapplication of the term “phobia.”
Social anxiety d/o typically permeates all of a person’s life. E.g.: fear of social situations and events, not panic attacks.
Social anxiety and agoraphobia are distinct enough D/O’s to warrant separate classification.
So which is it …
Social Phobia or Social Anxiety D/O?

3 Components of Anxiety: Physiological
Palpitations
Tachycardia
Dizziness
Nausea
Smothering
Lump in throat
Shakiness
Blurred vision
Chills
Headaches
Depersonalization
Tightness or pain in chest
Tinnitus
Shortness of breath
Flushing/blushing
Diarrhea
Parathesias

3 Components of Anxiety:Behavioral
2 Distinct Parts
What someone does in an anxiety-provoking situation:
Shuffle feet, avoid eye contact, clinch fists, etc.

Avoidance:
Not doing something that is frightening, or
Doing it in a way that one stays away from the most frightening aspects of the anxiety-provoking situation.

3 Components of Anxiety:Cognitive

Specific thoughts
“I’ll look stupid”
“No one will like me”
“I’ll make a fool of myself”

Though Process – the selective rehearsal (or reliving) of the process involved in past anxiety-provoking situations, which may involve specific, “automatic” thoughts.
DSM-IV Differential Diagnosisfor Social Phobia
Social Phobia must be differentiated from: Panic w/ agoraphobia

Agoraphobia w/o Hx of Panic, GAD, Specific Phobia In contrast to SP, the other condition:
Is typically not limited to social situations and is characterized by the initial onset of unexpected Panic Attacks.

Involves anxiety or avoidance that is not limited to situations that involve scrutiny by others.
DSM-IV Differential Diagnosisfor Social Phobia
Social Phobia must be differentiated from: Sep Anxiety D/O

Pervasive Develop D/O, Schizoid PD
In contrast to SP, the other condition:

Is characterized by fears concerning sep from caretakers.
Is characterized by avoidance of social situations due to a lack of interest in relating to other individuals.
DSM-IV Differential Diagnosisfor Social Phobia

Social Phobia must be differentiated from: Avoidant PD
In contrast to SP, the other condition:
Is conceptualized as a PD but may describe the same group of pxts as Social Phobia, Generalized type. For persons with Social Phobia, Generalized type, dx of Avoidant PD should be considered.
DSM-IV Differential Diagnosisfor Social Phobia

Social Phobia must be differentiated from: Social anxiety & avoidance w/ other mental D/Os.

Non-pathological performance anxiety, stage fright, or shyness.
In contrast to SP, the other condition:
Is characterized by anxiety that occurs only during the course of the other mental d/o.
Lacks clinical significant impairment or marked distress.

Rationale for CBT

According to Dx criteria, Social Phobia is the fear of social interactions with others (usually strangers) or situations in which others may scrutinize or judge the behavior or actions of the person (e.g., embarrassment or humiliation). This fear(s) is based on two factors:
Past experience(s) repeating in the present
Interpretation of past & future experience(s)

While past experiences are not, in themselves, the focus of CBT, when past meets present or impacts, impedes, or influences the future, CBT can be very effective, especially when there is such a strong interpretive set.

Antecedent Event  Bx  Consequence
Bx is not based on AE, but on one’s interpretation of or belief about the AE.

Empirical Research

Originating with the publication of DSM-III, social phobia was conceptualized as anxiety in a single situation (akin to simple phobia), and socially anxious persons with a more generalized presentation received as Dx on Axis II of Avoidant PD (Craig, Heimberg, & Hope, 1992).

This was based on the premise that most social phobics experience anxiety in only one social situation. This premise has been challenged on empirical and conceptual grounds.

DSM-III-R modified social phobia to include a generalized subtype allowing for fear in most social situations.

DSM-IV-TR continues to maintain this subtype of social phobia.
Current researchers propose changing the name from Social Phobia to Social Anxiety Disorder, with two subtypes: generalized and specific.

1992a study (Holt, Heimberg & Hope): comparison & contrast of Avoidant PD and generalized subtype of Social Phobia.

Anxiety Disorders Interview – Revised (ADIS-R)
Clinician’s Severity Rating (CSR)
Personality Disorders Examination (PDE)
Liebowitz Social Phobia Scale (LSPS)
Social Avoidance & Distress Scale (SADS)
Fear of Negative Evaluation Scale (FNES)
Fear Questionnaire (FQ)
Social Interaction Anxiety Scale (SIAS)

Results:
Generalized SPs w/ or w/o APD and non-generalized SPs w/o APD can be distinguished on measure of phobic severity.

Generalized group shows earlier onset than non-generalized group.
Some difficulty in differentiating Generalized SPs and APD – further research needed to provide clinical distinctions b/t 2 groups.

1992b study (Herbert, Hope, & Bellack): distinction between Generalized Social Phobia and Avoidant Personality D/O.

Social Phobia Anxiety Inventory (SPAI)
Social Avoidance & Distress Scale (SADS)
State-Trait Anxiety Inventory – Trait (STAI-T)
Beck Depression Inventory (BDI)
Symptom Checklist 90 – Revised (SCL-90-R)
Fear of Negative Evaluation Scale (FNES)
Empirical Research

Results:
Discriminative examination of GSP and APD indicate high degree of comorbidity between 2 conditions.
All pxts who were diagnosed as APD also met DSM IV-TR criteria for GSP.
APD was associated with greater social anxiety and functional impairment, but no differences were found in social skills or impromptu speech performance.
Quantitative differences of same d/o that involve probable qualitative distinction based on degree of impairment.

1993 study (Chambless & Gillis): effectiveness of cognitive therapy of anxiety d/o’s, including social phobia.

Fear of Negative Evaluation Scale (FNES)
Irrational Beliefs Test (IBT)
Social Interaction Self-Statement Test (SISST)
Social Phobia subscale of Fear Questionnaire
Social Avoidance & Distress Scale (SADS)
Empirical Research

Results:
Consistently large pre-post effect sizes reflect substantial & significant within-group change.
Waiting list, supportive control group txt, CBT txt
FNES is best predictor of txt outcome due to:
Fear of scrutiny
Negative evaluation by others

1997 study (Safren, Heimberg, & Juster): Client’s expectations & their relationship to pretreatment symptomatology & outcome of CBGT for social phobia.
DSM-III-R or DSM-IV criteria based on clinical interview
Anxiety D/O Interview Schedule – Revised (ADIS-R)
Anxiety D/O Interview Schedule – DSM IV – Lifetime (ADIS-IV-L)
Empirical Research

Results:
CBGT, Heimberg protocol
Cognitive restructuring skills & exercises
Repeated exposure to simulations of feared situations in group
Related homework
Results to Treatment Questionnaire (RTQ)
Significant & consistent negative correlation with ADIS-R, Interaction fear (SIAS & LSAS), LSAS Performance subscale, BDI, and HRS-D.
CBT Protocol forSocial Anxiety D/O
Developed by Hope, Heimberg, Juster, & Turk.
“Managing Social Anxiety: A Cognitive-Behavioral Therapy Approach,” 2000, TherapyWorks.
Client workbook consists of 14 lessons (chapters), 14-20 sessions.
CBT Protocol for Social Anxiety D/O – Lesson 1
Introduction to the program
Defining social anxiety D/O
How to use the manual
How this CBT protocol can help
How to get the most out of this program

Overview of the program
Self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 2
Understanding Social Anxiety D/O
3 components of social anxiety
Physiological
Cognitive
Behavioral
Interaction between the 3 components
Homework
Self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 3
Further information about Social Anxiety
Possible causes of SA
Genetics
Family environment
Important personal experiences
Dysfunctional thinking patterns
Mechanism of action – cognitive examples
Mechanism of action – physiological arousal
Mechanism of action – behavioral response
CBT Protocol for Social Anxiety D/O – Lesson 3 (Con’t)
Summary of development of social anxiety and dysfunctional beliefs.
FAQ, re: causes of SA & dysfunctional beliefs
CBT for SA

What’s involved
Systematic graduated exposure
Cognitive restructuring
Homework assignments
Homework & self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 4
Gathering situation-specific information
Fear & avoidance hierarchy
Brainstorming
Rank ordering the situations
Discovering dimensions that increase or decrease the situations
Rating each situation for fear & avoidance
SUDS: subjective units of discomfort scale
Avoidance ratings
Homework & self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 5
Identifying thoughts that cause anxiety
Homework review
Importance of thoughts
Relationship b/t events, thoughts, & feelings
Exploring client thoughts
How others may react to client thoughts
Automatic thoughts
Identifying ATs & the emotions they cause
Identifying client ATs & emotions they cause
Homework & self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 6
Tools to challenge client ATs
Defining thinking errors
All-or-nothing thinking Mental filter
Fortune telling Mind reading
Catastrophizing Overgeneralization
Disqualifying or Labeling
discounting the positive
Emotional reasoning “Should” or “Must” statements
Maladaptive thoughts

CBT Protocol for Social Anxiety D/O – Lesson 6 (Con’t)
Tools to challenge client ATs
Identifying thinking errors in client homework ATs
Challenging client ATs
Finding logical errors in client ATs
Combating ATs with rational responses
Homework
Self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 7
Exposure treatment
How exposure txt is helpful
First in-session exposure
Picking a situation
Cognitive restructuring
Working out the details of exposure situation
Setting achievable behavioral goal
Setting the goal of not being anxious
Importance of goal-setting
Completing the exposure
CBT Protocol for Social Anxiety D/O – Lesson 7 (Con’t)
Exposure treatment (con’t)
Do’s & don’ts of therapeutic exposure
Debriefing the exposure
Homework after first in-session exposure
Homework
Self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 8
Ongoing in-session and homework exposures
How to pick exposure situations
Easier before harder
Build into a sequence of exposures
Use exposures to challenge ATs
How cognitive restructuring changes as clients tackle different situations
Relationship between exposures, cognitive restructuring, & homework
CBT Protocol for Social Anxiety D/O – Lesson 8 (Con’t)
Ongoing in-session and homework exposures
Summary of the course of txt program

FAQs
Homework for the rest of the program
Weekly exposure homework
Self-monitoring homework
Making overcoming anxiety a new habit
Self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 9
Overcoming fears of doing things in front of others (like Powerpoint presentations)
“Original” social phobic behavior
Common ATs related to observational fear & how to handle these ATs
“My hand(s) will shake”
Uncovering & challenging the ATs
Setting reasonable behavior goals
In-session and homework exposure
CBT Protocol for Social Anxiety D/O – Lesson 9 (Con’t)
Overcoming fears of doing things in front of others
“I’ll make a mistake”
Uncovering & challenging the ATs
Setting reasonable behavior goals
In-session and homework exposure
Exposures for observational fears
Eating or drinking in front of others
Writing in front of others
Fear of making mistakes
Homework & self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 10
Big fears of small talk
Big impact of small talk
Small talk begins relationships
Social support networks
Examining client’s SSN
Common ATs for casual conversations
“I won’t know what to say”
“I’m not very good at making conversation”
Homework
Self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 11
Public speaking
Similar to lesson 9, but more specific & intensely anxiety provoking (specific phobia?)
#1 fear in USA
Identifying & challenging ATs
Setting achievable behavioral goals
In-session exposure
“Screening room” rehearsal (group txt)
Homework & self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 12
Advanced cognitive restructuring work
Addressing core beliefs
Searching for common themes in client ATs
Discovering client core beliefs
Peeling the onion
Not all core beliefs are hard to find
This is not about your past or how your mother treated you
Self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 13
Becoming your own coach: habituation & generalization
Progress checklist
How to continue the journey
New situations = new challenges
Reactions from others
You’re on your own, but I’ll be here
Self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 14
Medication treatment for social anxiety
How medications affect the brain & reduce SA
SSRIs
MAOIs
Beta-adrenergic blockers
Benzodiazepines
General considerations concerning medication treatment for social anxiety
Treatment “cocktail”: therapy & medication
Self-assessment

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In addition, my son felt like he lost his place, as ‘the baby’, in the family when we adopted another child five years ago. Then, a year ago, we adopted again (through the foster parenting system). Despite our best intentions my son has felt left out and unloved.

Things became worse when my son began smoking pot (alone in our home). We went to therapy and he ‘promised’ to quit, but was caught several times after that. He despises my husband and says he was never there for him. I see that he has projected his feelings of loss of his biological father onto my (type A) husband. My son is currently living with his biological father and won’t speak to my husband (although he warmed up to me after 4 weeks and my realization that I was not there for him to talk to). What can be done to bridge the gap when my son won’t even speak to his step-dad?

Dear Anonymous,

I am going to do my best to respond to your question, with the information that you provided. However, some of what I am going to write in my response is going to be speculation. It seems finding a good licensed family therapist might be very helpful for receiving the best counsel.

On Being a Step-parent, or being part of a “Blended Family”

It’s difficult to be a parent, and especially difficult to be a step-parent, or a biological parent in part of a “Blended Family.” But you are not alone. Today, only one of every four families is a traditional ‘nuclear’ family. That is, a mother, a father, and biological children.

About ½ of all marriages this year will end in divorce, and in most developed countries ½ of all births are to unmarried women. This means the blended family is the norm, not the exception.

Blended families result when a parent marries a person who is not the biological father of their child (or, some contend, when a couple adopt a child that is not their own). Often, if the marriage occurs while the child is still very young, the family looks identical to the traditional nuclear family. However, most blended families contain children from only one of the two parents.

Being part of a blended family can be very stress provoking for the persons involved (both parents, step parents, and kids). Some common stressors that are often overlooked include:

• new living arrangements,
• new family members,
• new schools,
• new traditions,
• new house rules,
• the loss of friends,
• being displaced from relatives,
• a new church,
• and a new last name, to name a few.

Children in blended families are rarely as thrilled about the remarriage as the newly-married parents are. This can create problems unless it is dealt with early and sensitively. It will take both time and energy to build relationships between step-parents and step-kids.

Moreover, often children feel that by loving and accepting a step-parent they are rejecting their biological parent. This can further complicate matters. And to add another complex layer, parents in blended families often struggle with loyalty issues arising from feeling that they should defend their children against the step-parent or step¬siblings.

Visitation is a common source of stress and angst with blended families. Children often experience two realities, one with the blended family and the other with the biological parent. Life can get even more complicated if the biological or non-custodial parent remarries to create yet another blended fam¬ily! Visitation arrangements also become tricky if the non-custodial parent is physically distant.

Some Basic Coaching Tips and Guidelines

1. Mourn any family losses and transitions.

Persons in blended families, especially kids, should be able to share their feelings of loss and their memories of how things used to be. These topics should never be taboo—but encouraged! It should be acknowledged and respected that all members of the blended family will need time to feel normal again. If a family member is having a hard time adjusting, it does not mean he/she does not care for the new person in the family.

2. Understand kids’ development.

Members of blended families are not always 100 percent knowledgeable of the needs of family members. This is especially true when kids are involved. For example, a step-parent who has not had kids will probably not know what to do with a toddler, or a per-teen, or even a teenager. And even is he/she has raised his/her own kids, they were likely quite different and did not experience the same challenges of the kids present in the blended family. Parents and step-parents can help themselves and their children by learning about age and maturity level appropriate ways to raise children, and by studying ways to better build relationship with step-kids.

3. Establish new family traditions.

While not rejecting the traditions of the previous family life or those of the non-custodial parent, it is good for the blended family to create some of its own family traditions. This is important for building cohesion and a sense of unity in the family. Note however that each member of the blended family has his/her own history, memories and perceptions and is being asked to merge and com¬promise them with those of other family members. What was once familiar is being turned on its head: Christmas, Easter, Halloween, birthdays, vacations, etc. Though it may seem like a small issue, family traditions are not easily surrendered by persons who ¬have already gone through many other changes. Final note, even as the family develops new traditions and rituals, visitation time with the biological parent should always be respected, especially during important events and holidays.

4. Maintaining a healthy marriage.

Spouses must be intentional about keeping their marital partnership strong. Instruct the couple to take time alone to love-on, show affection to, support, talk-to, be present with, and care for one another. A strong marriage is a crucial part of the overall functioning and stability of the family.

5. Cooperation with the biological parent.

If at all possible, include the non-custodial/biological parent in the life of the children. Kids, especially teenagers, are greatly stabilized by seeing their parents unified. For this, mom and dad should try to minimize contention—especially in front of the kids. Consistent parenting helps to alleviate children’s insecurity following divorce.

More Parenting Strategies for your Son:
It seem that your son is currently about 16 years old, and that the relationship problems exist both between your new husband, and yourself. Here are some ideas that might make a difference quickly

1) Don’t attack the Biological Parent—I noticed you did a little attacking in your question, calling him a “Disney Land Dad.” Instead, team with the biological parent as much as possible.

2) You acknowledged in your email that you haven’t been as available for your son, to talk with, as you thought; the foster parenting / adoptions might also make this challenging. Know that it’s never too late to make changes, and to find more ways to connect with your son (also see recommendations below)

3) You describe your new husband as “Type-A”. Persons with Type-A personalities are often very driven, but sometimes lack patience, tenderness, and Time. Remember that Kids spell love T-I-M-E. Also, if your son has a different disposition/personality from your husband, he will need to work extra hard to connect with your son.

Final Thoughts

Parenting is not an easy task. As a parent you are given the authority over your children and must assume control of how they are raised.

One’s role as a parent is constantly changing. As children grow older and mature, one’s role becomes less active until eventually they serves as a friends and advisor to their adult children.

There are various key components that contribute to good parenting. Among the most important are:

1. Love. Children need physical contact, hugs, words of encouragement and affirmation, and quality time- all of which communicate love. Love is able to break down walls and barriers that one cannot otherwise see. Although children- especially adolescents- may pull away at times, it is normal and is often due to the fact that they are simply learning how to act and think on their own. Parents are to love their children even when they are heartbroken by or disagree with their children’s actions, or feel that it is undeserved. A parent’s love for their child is always unconditional.

2. Discipline. Discipline is unlike punishment in that it always intends for a better future for the child. When it comes to discipline, parents must always keep a balance, be consistent, firm, and follow through on their word.

3. Guidance. As a parent, it is your responsibility to guide your children and to teach them about life. At times, this may mean allowing them to make their own mistakes. As a result, parents should be prepared to be disappointed with their children’s choices or behaviors from time to time. However, having such disappointment is better than making the mistake of helping children to get out of their difficulties too readily. By allowing children to make mistakes, parents are actually allowing a great amount of growth to take place.

FINAL ADVICE

When one is having problems with parenting, it is probable that a few changes may need to be made. While such changes may be difficult at first, they will not be impossible.

When parenting strong-willed or tough children, it is important for parents not to panic when they think about the future of their child. Some of the most difficult children become the more successful adults. So no matter what the case, parents should always envision the most positive futures for their children. They should also be sure to share those visions lovingly with their children and set aside plenty of time to share with them.

Action steps that may be helpful for every parent to keep in mind are:

1. Focus on relationship.
The quality of the parent-child relationship will determine just how effective discipline strategies are.

2. Be consistent.
Parents need to work together. Children must not think that they can pit parents against one another or get one parent to overrule the other.

3. Spend time together.
Spend as much quality time as a family as possible. If it is only one meal a day, then eat one meal a day together. It is of foremost importance for parents to maintain the strongest relationship possible with their children.

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DIAGNOSTIC CRITERIA

Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities.

The person finds it difficult to control the worry.

The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some present for more days than not for the past 6 months)

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

D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, the anxiety or worry is not about having a panic attack, being embarrassed in public, being contaminated, being away from home or close to relatives, gaining weight, having multiple physical complaints, or having a serious illness, and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.

E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and does not occur exclusively during a Mood Disorder, a Psychotic disorder, or a Passive Developmental Disorder.

ASSOCIATED FEATURES AND DISORDERS

Associated with muscle tension
Trembling
Twitching
Feeling shaky
Muscle aches or soreness

Many individuals with GAD also experience somatic symptoms:

Sweating
Nausea
Diarrhea
Exaggerated startle response
Accelerated heart rate
Shortness of breath
Dizziness

GAD very frequently co-occurs with Mood Disorders (Major Depressive or Dysthymic Disorder), with other Anxiety Disorders (Panic Disorder, Social Phobia, Specific Phobia), and with Substance Related Disorders (Alcohol or Sedative, Hypnotic, or Anxiolytic Dependence or Abuse).

Other conditions that may be associated with stress (irritable bowel syndrome, headaches) frequently accompany GAD

SPECIFIC CULTURE, AND AGE FEATURES

There is considerable cultural variation in the expression of anxiety in some cultures. It is important to consider the cultural context when evaluating whether worries about certain situations are excessive. In some cultures, anxiety is expressed predominately through somatic symptoms, while in others, it is expressed through cognitive symptoms.

In children and adolescents with GAD, the anxieties and worries often concern the quality of their performance or competence at school or in sporting events, even when their performance is not being evaluated by others.

There may be excessive concerns about punctuality. They may also worry about catastrophic events such as earthquakes or war. Children with the disorder may be overly conforming, perfectionist, and unsure of themselves and tend to redo tasks because of excessive dissatisfaction with less than perfect performance. They are typically overzealous in seeking approval and require excessive reassurance about their performance and their other worries.

GAD may be over diagnosed in children. In considering this diagnosis in children, a thorough evaluation for the presence of other childhood Anxiety Disorders should be done to determine whether the worries may be better explained by another disorder.

GENDER FEATURES

In clinical settings, the disorder is diagnosed somewhat more frequently in woman than in men

About 55% -60% of those presenting with the disorder are female. In epidemiological studies, the sex ratio is approximately two-thirds female.

PREVALENCE

In a community sample, the one year prevalence rate for GAD was approximately 3%, and the lifetime prevalence rate was 5%. In anxiety disorder clinics, up to a quarter of the individuals have GAD as a presenting or co morbid diagnosis.

COURSE

Many individuals with GAD report that they have felt anxious or nervous all of their lives. Although over half of those presenting for treatment report onset in childhood or adolescence, onset occurring after age 20 is not uncommon. The course is chronic but fluctuating and often worsens during times of stress.

FAMILIAL PATTERN

Anxiety as a trait has a familial association. Although early studies produced inconsistent findings regarding familial patterns for GAD, more recent twin studies suggest a genetic contribution to the development of this disorder. Furthermore, genetic factors influencing risk of GAD may be closely related to those for Major Depressive Disorder.

DIFFERENTIAL DIAGNOSIS

GAD must be distinguished from an Anxiety Disorder Due to a General Medical Condition. The diagnosis is Anxiety Due to a General Medical Condition if the anxiety symptoms are judged to be a direct physiological consequence of a specific general medical condition.

A substance Induced Anxiety Disorder is distinguished from GAD by the fact that the substance is judged to be etiologically related to the anxiety disturbance.

Several features distinguish the excessive worry of GAD from the obsessional thoughts of Obsessive Compulsive Disorder. Obsessional thoughts are not excessive worries about everyday or real life problems, but rather are ego-dystonic intrusions that often take the form of urges, impulses, and compulsions that reduce the anxiety associated with the obsessions.

Anxiety is invariably present in Posttraumatic Stress Disorder. GAD is not diagnosed if the anxiety occurs exclusively during the course of PTSD. Anxiety may also be present in in Adjustment Disorder, but this residual category should be used only when the criteria are not met for any other Anxiety Disorder.

RATIONALE FOR CBT TREATMENT

Silverman (2003) postulated that in the past decade, research from randomized clinical trials have produced strong and consistent evidence that cognitive-behavioral therapy (CBT) can play an important role in reducing Social Phobia, Separation Anxiety, and Generalized Anxiety Disorder in Children and Adolescents.

The author proposed therapeutic procedures and strategies used in CBT in three phases:

Education:

In the education phase, children first receive information that anxiety may manifest in three ways:

Feelings in their bodies

Certain behaviors such as avoiding or staying away from events that may be anxiety provoking.

3. The things we say to ourselves( self talk).

The situations avoided and the anxious thoughts vary among patients. During the education phase, children learn to identify the situations and the nature of their thoughts.

In GAD, children engage in frequent , uncontrollable worry, The worry thoughts vary and may focus on everything and anything, or specific areas such as personal health, parent’s health, their performance in school, or world events. Children with GAD may also show avoidant behaviors, such as not eating in restaurants.

Application:

In the application phase, children (and parents, if they are involved) practice the principles and procedures taught in the beginning sessions. This application occurs in the therapy session and out-of-session as homework assignments. The therapist’s role is similar to a coach in terms of providing feedback, support and encouragement as the child engages in increasingly difficult anxiety provoking exposure tasks.

Relapse Prevention

As the child meets with continued success, the therapist should begin discussing with the child issues relating to termination, including relapse prevention. Specifically, the importance of continued exposures should be emphasized.

ROLE OF POSITIVE BELIEFS

Wells et.al (1999) presented a comprehensive theory regarding the importance of “Meta-Worry” in understanding GAD, positing that individuals who suffer from GAD hold a variety of beliefs about possible benefits of their worrying. Their research suggests a strong argument for the use of CBT as a viable treatment for GAD.

Borkovec, Hazlett-Stevens, & Diaz (1999) asked GAD clients what they believed might be the benefits of worrying?

If I worry about something, I am more likely to actually figure out how to avoid or prevent something bad from happening.

Although it may not actually be true, it feels like if I worry about something, the worrying makes it less likely that something bad will happen.

Worrying about most of the things I worry about is a way to distract myself from worrying about even more emotional things, things that I don’t want to think about.

If I worry about something, when something bad happens, I’ll be better prepared for it.
Worry helps to motivate me to get things done that I need to get done.

Worrying is an effective way to problem solve.

STUDY I
The authors constructed a questionnaire which presented the reasons for worry, and asked GAD and control groups to rate items and asked analog GAD and control groups to rate the extent to which each statement described a reason for why they worried.

In Study I, a small group of college students meeting criteria for GAD was compared to a nonanxious group and a group who met some but not all GAD criteria. The items referring to worry as avoidance, preparation and problem solving were most highly endorsed overall.

Between group differences were limited to use the worry as a distraction from emotional topics, where the GAD group scored significantly higher than the nonanxious group.

STUDY II
In Study II, the same scales were administered to a large sample of GAD participants, nonanxious controls, and controls who met GAD criteria from somatic symptoms but did not experience excessive worry. The same three items were most highly rated by the entire group. The GAD participants were, however, significantly more endorsing of worry as a useful problem solving device, and of the feeling that worry makes bad things less likely to happen than the nonanxious group, and they were significantly more characterized by the use of worry as a distraction than both control groups.

STANDARD AND ENHANCED CBT FOR LATE-LIFE GAD

Mohlman et.al (2004) hypothesized that as the U.S. population ages, mental health professionals are becoming more concerned about effective treatments for late-life anxiety. The authors stated that it is currently unclear whether treatment strategies used successfully with younger adults are appropriate for older adults.

“The efficacy of CBT for anxiety is one promising strategy currently being investigated in elderly population samples.”

The authors further stated that although CBT is an efficacious treatment for GAD in younger adults, little is known about its efficacy in older adults.

PARTICIPANTS AND MEASURES

The authors stated that to their knowledge, their two small pilot studies are the first investigations of CBT delivered in a mental health clinic in individual format. “Study I tested a standard version of CBT, and Study II tested a version that was enhanced with learning and memory aids designed to make the therapy more effective for the elderly.”

STUDY I
Study I participants included 27 adults age 60 to 74, with a mean age of 66.4. Continuous demographic and clinical variables were compared between the groups in Studies I and II using multivariate analyses of variance (MANOVA). “There were no significant differences on variables in either sample.”

ANALYSIS OF STUDY I
At posttreatment, 50% of the CBT group and 31% of the wait list group were free of GAD, and 45% of the CBT group and 23% of the wait list group were free of comorbid diagnosis. “At follow-up, an additional 36% of the CBT group was GAD free and an additional 30% were free of comorbid diagnosis.”

STUDY II
Study II participants were randomly assigned to either 13 50 minute sessions of enhanced CBT (ECBT- n=8) followed by monthly booster sessions for six months, or a 13 week wait list condition (n=7).

ANALYSIS OF STUDY II
At posttreatment, 86% of the ECBT group and 14% of the wait list group were free of GAD, a difference that unlike Study I was statistically significant. “At follow-up, 86% of the ECBT group remained free of GAD, 63% of the ECBT group was free of comorbid diagnosis at posttreatment.

DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF THE SAMPLE
Study I Study II
wait CBT Wait ECBT
(n=13) (n=14) (n=7) (n=8)
———————————————————————-
Age 65.69 67.14 66.89 68.50
(4.71) (5.30) (9.81) (11.42)
Ethnicity
White 100% 86% 83% 86%
Hispanic O% 14 % 17% 0%

Major 1.78 1.46 1.00 1.25
Health (1.86) (1.27) (1.08) (1.01)

Minor 1.67 0.77 0.87 2.65
Health (1.58) (0.73) (1.13) (0.97)

Comorbid 1.08 0.67 0.87 2.65
(1.04) (0.71) (0.89) (0.70)

Late Onset 38% 50% 50% 70%

The authors stated that Major health problems were defined as those that required inpatient surgery, were life threatening or caused impairment despite ongoing medication. “Minor health problems were those that required outpatient care or those that were effectively controlled with medication.”

TREATMENT STEPS OF CBT

In their workbook, Mastery of Your Anxiety and Worry, Craske, Barlow & O’Leary
(1992), proposed a worry record. Participants are asked to list their anxiety symptoms, and rate their level of severity. Symptoms could be rated as none, mild, moderate, strong, or extreme. Furthermore, participants are then asked to list the events which may cause anxiety, as well as the anxious thoughts themselves on a worksheet. They call this worksheet the Worry Record Form.

SYMPTOMS
Trembling
FATIGUE
SWEATING
NAUSEA
TROUBLE SWALLOWING
TROBLE SLEEPING
MUSCLE TENSION
DIFFICULTY BREATHING
DRY MOUTH
HOT FLASHES
KEYED UP
DIFICULTY CONCENTRATING
RESTLESSNESS
POUNDING/ RACING HEART
DIZZY
FREQENT URINATION
EASILY STARTLED
IRRITABILITY
EVENTS
FAMILY
FRIENDS
WORK
SCOOL
HOME MANAGEMENT
FINANCAIL
HEALTH
OTHER
Anxious thoughts

After a person has spent several weeks filling out the Worry Record sheets, they need to examine the patterns from the very beginning of the program to the present. “It is possible that the worry exposure practices could result in a higher level of anxiety. This is normal, because you are being asked to focus on the very things that you worry about.

The next step toward gaining control over your worry and anxiety entails some work in everyday kinds of situations. Preventing worry behavior involves a set of procedures designed to put an end to avoiding certain thoughts or situations.

INSTRUCTIONS FOR WORRY BEHAVIOR PREVENTION EXERCISES

1. Consider the practical aspects of the task; what you must do or not do, and how you will do or not do the behavior. The tasks may entail some planning, such as asking a friend to let your children sleep over, or arranging a dinner party. In addition, inform your family members or friends of any changes in behaviors that have affected them in the past.

2. Consider the types of worries that will come to your mind and how to counter them. That is, have your realistic thinking strategies prepared to deal with the worry that you feel when practicing.

3. Practice each task the number of times necessary for maximum anxiety levels to reduce to a mild level. Depending on the task, you may be able to repeat the practices quickly, such as one day after another, or over longer periods of time.

4. Spend the next few weeks, or however long it takes, to practice these tasks. The authors recommend that a person attempt to do at least one task each day.

POTENTAIL DIFFICULTIES WITH WORRY PREVENTION EXERCISES

Procrastination
Immediate anxiety
Being unprepared
Impractical tasks
You experience little or no anxiety
Anxiety levels do not decrease

TIME MANAGEMENT

Three basic principles for helping you to manage your time:

Delegating responsibility
Saying no
Sticking to agendas

BRAINSTORMING

When you are faced with real life problems or a crisis, do the following:

Write down what the problem is
Let your mind go and write down every possible solution that comes to you
Rank order these solutions from best to worst, based on how practical and reasonable they are to do
Decide on a specific plan of action in order to carry out each reasonable solution. Rate the probability of each solution’s working.

Put the plan for the most reasonable solution into action. If it does not help the problem, move down your list to the next best solution, and try again until you can successfully resolve the problem or make it better.

GET STARTED TODAY

So what are you waiting for? The treatment plan could be much more “enlightening” than you ever dreamed!

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Thanks for this question about being a caregiver—let me give it a shot.

Also, before you sent this question you wrote me briefly to explain you are particularly interested in caregiving as it applies to caring for aging parents—so I tried to focus on that area of care-giving in specific.

Caring for aging parents can be a rewarding and gratifying experience.

However, just how gratifying it is can depend on a lot of different issues including:
• Your own health
• Your financial resources
• Your emotional resilience
• and whether or not you are raising children (or caring for others as well).

So while being a caregiver is commendable, it is not the best option for everyone.

The Sandwich Years

The “sandwich years” is an expression that refers to middle-aged people who are both raising children of their own and caring for their parents. They are “sandwiched” between two generations, and it can often feel like a well-coordinated dance, or sometimes a vice grip.

Challenges with Caring for the Aged

There are some unique challenges to caring for aging persons.

First, there is a tendency that as people age, their idiosyncrasies often become more pronounced. Those who are easygoing will most likely continue to be laid back. However, some persons can become increasingly anxious, uptight, or paranoid with age.

Second, as people undergo the aging process, they are likely to experience many transitions and even losses. Such personal losses can include lessened physical abilities, lower energy and strength, retirement (loss or career), a loss of a sense of purpose, the transition from parent to grandparent, deaths of peers and friends, a tighter financial budget, the loss of a spouse, and lowered social status.

Because of these many losses, at times caring for the elderly means providing support for grief and bereavement an elderly person may be experiencing.

Preserving Independence and Health Through the Years

Poor health and loss of independence are not inevitable consequences of growing older. There are a number of strategies to preserve health and independence for older people and their caregivers to consider. They include:

1. Early disease detection.

Older people should be encouraged to participate in any screenings recommended to them. Screening to detect diseases early- at the stage when they are most easily treated- saves many lives.

2. Healthy lifestyle.

Having a healthy lifestyle is more powerful than a person’s genes in helping people to avoid the decline usually associated with aging.

3. Immunizations.

Important immunizations like flu shots or pneumonia vaccines reduce one’s risk for hospitalization and death as a result of illness.

4. Injury prevention.

Installing grab bars in key areas (i.e., bathrooms) and removing tripping hazards in the home will significantly reduce an older person’s likelihood of falling and injuring themselves.

5. Programs to aid in self-management and adaptation.

There are several counseling programs that exist in order to teach older people self-management techniques and to help them to cope with and manage the transitions that will accompany their later years.

Find the Best Possible Living Situation

In terms of determining the proper living situation for an elderly person, it is best to begin by having the caregiver and elderly person rank the person’s needs together and in order of importance. Determine how those needs could be met through minimal upheaval- often the choice is not necessary between living alone or in a nursing home.

There are actually many options in between the two extremes: care in a group home; skilled nursing care; non-medical home care for meals, cleaning or home maintenance (i.e., meals on wheels); aid at home during key hours of the day for things like bathing and dressing; assisted living or sheltered/catered care (i.e., situations that provide meals, transportation to stores, medication reminders, or other support services); shared housing with a younger, non-family member; adult daycare for those who have friends or family with them at other times; retirement home living; and senior housing complexes that are apartment complexes that provide extra support at a lower price to needy older people.

In determining the proper living situation for an elderly person, it is also important to consider that any changes in lifestyle will affect all family members involved in their life and to keep upheaval to a minimum- particularly if the family life of caregivers is already demanding or intense.

Also, it is crucial to consider all of the options and to enlist several people in the decision-making process.

Last, one should remember that giving en older person something to live for (i.e., hobbies, love, purpose) and a sense of structure and stability through schedules can add an amazing amount of confidence to an older person’s everyday life.

Abuse and Neglect in Caregiving

Financial abuse occurs when family members or friends take financial resources from an elderly person for their own benefit. It is a particular risk when the elderly person is no longer in control of his or her own finances or when they tend to become easily confused.

Elder neglect occurs when the people an older person is living with deliberately neglect their needs for food, shelter, clothing, protection from extremes in temperature, and a clean environment. This can occur inadvertently if a previously healthy spouse or live-in family member becomes sick or confused and is unable to continue providing a safe environment for the older person.

Elder abuse occurs when physical violence is directed at an older person. It could be from a family or stranger that is the older person’s caregiver, or it could be domestic violence that has been ongoing toward a victim that is now over the age of 65.

Preventing Emotional Exhaustion as a Caregiver

1. Gain Perspective

Gain some perspective on what is causing the stress and exhaustion.
“Break apart” the stress overload into manageable pieces, and begin to address each component. It might just be a couples areas of being a caregiver that are causing stress.

2. Find Purpose

One of the best antidotes to stress is finding purpose in what you are doing.
If difficulties are for a valid and greater purpose, you might find yourself having more energy to manage them.

3. Get Rest

Planned times of quiet and solitude are a good balance to a busy life.
Rest is an important component to having the mental and emotional capacity to be a caregiver.

4. Share Your Burden with Others

This can be done literally or figuratively. In other words, talking about your stressors can bring relief and support. Perhaps some of the stress is because you’re doing too much. When this occurs, try to find help!

5. Live Intentionally

Don’t major in minor things. At the end of life, many will realize that they spent most of their time on what mattered least, and the least time on what mattered most.

Decide what is really important, choose your priorities, and live for them. Become more intentional about the way you spend your time and energy. Learn to say no to things that are just not that important.

6. Remember Your Limits

Often our lives become filled with stress because we refuse to accept our limits.
Feeling overwhelmed may be a reminder that you are not living within the limits and boundaries that God has created for you. It may be time to reevaluate, cut back, say no, or slow down.

7. Laugh a Little

Allow for some levity in your life. A comic strip, a favorite saying, a joke. Keep these within sight.

8. Don’t Isolate

Caregivers often find it difficult to find the energy to get out and maintain healthy social relationships.
Find the time, and spend the energy to stat connected. While there is some cost in the short term, it will help you in the long run.

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I was out with some friends last week, and someone in our group asked me a question about counseling that I’ve heard before, and I think is probably a common question that’s not often answered. So, I thought I would talk about it here.

The question is this: “If I’m in counseling, is it possible that I could become dependent on my therapist?”
I think it’s a good question—nobody wants to become dependent on their shrink, or anyone else for that matter.

Let me try to demystify it:

1) If you’re in counseling, or thinking about counseling, you probably want some amount of guidance or support from your therapist. Hence, it’s true that you might rely somewhat on your therapist and coach. This is not necessarily bad—and reliance isn’t dependence. You might rely on your therapist similar to the way that a student relies on their teacher, or an apprentice on a mentor.

2) It’s normal to have some attachment to your counselor, because when counseling (or coaching) is going well, it’s a real relationship. This too is ok, because not all attachment is unhealthy—there is also healthy attachment. In fact, without some amount of attachment, the relationship might lack trust or understanding—two crucial things in counseling!

3) If you are in counseling and are worried about your level of dependency on your counselor—talk to him or her about it. If you have a good and ethical therapist, he or she is going to work to make sure the relationship is a healthy one—and your counselor should let you know if they think you are being too dependent or reliant on them.

4) Also, ask yourself if the counseling is helping you make progress in your life. Are you able to make independent choices better than when you first started counseling? If the answer is yes—it seems counseling is helping you become more independent, not less.

By the way, having the thought, “what would my counselor or coach think about this” when you’re making a decision, isn’t necessarily bad…

5) Lastly, if you’re worried that your relationship with your counselor is unbalanced (and I might get some feedback from other counselors out there on this tip) present your concerns to another professional in the field. Another therapist should be able to provide you feedback for your specific situation, and act as an impartial third party to help you determine is you are indeed becoming overly dependent on your therapist.

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