ANXIETY

BEHAVIORAL DEFINITIONS

1. Excessive and/or unrealistic worry that is difficult to control occurring more days than not for at least 6 months about a number of events or activities.
2. Motor tension (e.g., restlessness, tiredness, shakiness, muscle tension).
3. Autonomic hyperactivity (e.g., palpitations, shortness of breath, dry mouth, trouble swallowing, nausea, diarrhea).
4. Hypervigilance (e.g., feeling constantly on edge, experiencing concentration difficulties, having trouble falling or staying asleep, exhibiting a general state of irritability).
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LONG-TERM GOALS

1. Reduce overall frequency, intensity, and duration of the anxiety so that daily functioning is not impaired.
2. Stabilize anxiety level while increasing ability to function on a daily basis.
3. Resolve the core conflict that is the source of anxiety.
4. Enhance ability to effectively cope with the full variety of life’s anxieties.
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SHORT-TERM OBJECTIVES THERAPEUTIC INTERVENTIONS
1. Describe current and past experiences with the worry and anxiety symptoms, complete with their impact on functioning and attempts to resolve it. (1) 1. Assess the focus, excessiveness, and uncontrollability of the client’s worry and the type, frequency, intensity, and duration of his/her anxiety symptoms (e.g., The Anxiety Disorders Interview Schedule for the DSM-IV by DiNardo, Brown, and Barlow).
2. Complete psychological tests designed to assess worry and anxiety symptoms. (2) 2. Administer a client-report measure to help assess the nature and degree of the client’s worry and anxiety symptoms (e.g., The Penn State Worry Questionnaire by Meyer, Miller, Metzger, and Borkovec).
image 3. Cooperate with an evaluation by a physician for psychotropic medication. (3, 4) 3. Refer the client to a physician for a psychotropic medication consultation. image
4. Monitor the client’s psychotropic medication compliance, side effects, and effectiveness; confer regularly with the physician. image
image 4. Verbalize an understanding of the cognitive, physiological, and behavioral components of anxiety and its treatment. (5, 6, 7) 5. Discuss how generalized anxiety typically involves excessive worry about unrealistic threats, various bodily expressions of tension, overarousal, and hypervigilance, and avoidance of what is threatening that interact to maintain the problem (see Mastery of Your Anxiety and Worry—Therapist Guide by Craske, Barlow, and O’Leary). image
6. Discuss how treatment targets worry, anxiety symptoms, and avoidance to help the client manage worry effectively and reduce overarousal and unnecessary avoidance. image
7. Assign the client to read psychoeducational sections of books or treatment manuals on worry and generalized anxiety (e.g., Mastery of Your Anxiety and Worry— Client Guide by Zinbarg, Craske, Barlow, and O’Leary). image
image 5. Learn and implement calming skills to reduce overall anxiety and manage anxiety symptoms. (8, 9, 10, 11) 8. Teach the client relaxation skills (e.g., progressive muscle relaxation, guided imagery, slow diaphragmatic breathing) and how to discriminate better between relaxation and tension; teach the client how to apply these skills to his/her daily life (e.g., Progressive Relaxation Training by Bernstein and Borkovec; Treating GAD by Rygh and Sanderson). image
9. Assign the client homework each session in which he/she practices relaxation exercises daily; review and reinforce success while providing corrective feedback toward improvement. image
10. Assign the client to read about progressive muscle relaxation and other calming strategies in relevant books or treatment manuals (e.g., Progressive Relaxation Training by Bernstein and Borkovec; Mastery of Your Anxiety and Worry—Client Guide by Zinbarg, Craske, Barlow, and O’Leary). image
11. Use biofeedback techniques to facilitate the client’s success at learning relaxation skills. image
image 6. Verbalize an understanding of the role that cognitive biases play in excessive irrational worry and persistent anxiety symptoms. (12, 13, 14) 12. Discuss examples demonstrating that unrealistic worry typically overestimates the probability of threats and underestimates or overlooks the client’s ability to manage realistic demands (or assign “Past Successful Anxiety Coping” in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma). image
13. Assist the client in analyzing his/her fear by examining the probability of the negative expectation occurring, the real consequences of it occurring, his/her ability to control the outcome, the worst possible outcome, and his/her ability to accept it (see “Analyze the Probability of a Feared Event” in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma, and Anxiety Disorders and Phobias by Beck and Emery). image
14. Help the client gain insight into the notion that worry is a form of avoidance of a feared problem and that it creates chronic tension.  image
image 7. Identify, challenge, and replace biased, fearful self-talk with positive, realistic, and empowering self-talk. (15, 16, 17) 15. Explore the client’s schema and self-talk that mediate his/her fear response; challenge the biases; assist him/her in replacing the distorted messages with reality-based alternatives and positive self-talk that will increase his/her self-confidence in coping with irrational fears. image
16. Assign the client a homework exercise in which he/she identifies fearful self-talk and creates reality-based alternatives; review and reinforce success, providing corrective feedback toward improvement. image
17. Teach the client to implement a thought-stopping technique (thinking of a stop sign and then a pleasant scene) for worries that have been addressed but persist (or assign “Making Use of the Thought-Stopping Technique” in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma); monitor and encourage the client’s use of the technique in daily life between sessions. image
image 8. Undergo gradual repeated imaginal exposure to the feared negative consequences predicted by worries and develop alternative reality-based predictions. (18, 19, 20, 21) 18. Direct and assist the client in constructing a hierarchy of two to three spheres of worry for use in exposure (e.g., worry about harm to others, financial difficulties, relationship problems). image
19. Select initial exposures that have a high likelihood of being a success experience for the client; develop a plan for managing the negative affect engendered by exposure; mentally rehearse the procedure. image
20. Ask the client to vividly imagine worst-case consequences of worries, holding them in mind until anxiety associated with them weakens (up to 30 minutes); generate reality-based alternatives to
that worst case and process them (see Mastery of Your Anxiety and Worry—Therapist Guide by Craske, Barlow, and O’Leary). image
21. Assign the client a homework exercise in which he/she does worry exposures and records responses (see Mastery of Your Anxiety and Worry—Client Guide by Zinbarg, Craske, Barlow, and O’Leary or Generalized Anxiety Disorder by Brown, O’Leary, and Barlow); review, reinforce success, and provide corrective feedback toward improvement. image
image 9. Learn and implement problem-solving strategies for realistically addressing worries. (22, 23) 22. Teach problem-solving strategies involving specifically defining a problem, generating options for addressing it, evaluating options, implementing a plan, and reevaluating and refining the plan. image
23. Assign the client a homework exercise in which he/she problem-solves a current problem (see Mastery of Your Anxiety and Worry—Client Guide by Zinbarg, Craske, Barlow, and O’Leary or Generalized Anxiety Disorder by Brown, O’Leary, and Barlow); review, reinforce success, and provide corrective feedback toward improvement. image
image10. Learn and implement relapse prevention strategies for managing possible future anxiety symptoms. (24, 25, 26, 27) 24. Discuss with the client the distinction between a lapse and relapse, associating a lapse with an initial and reversible return of worry, anxiety symptoms, or urges to avoid, and relapse with the decision to continue the fearful and avoidant patterns. image
25. Identify and rehearse with the client the management of future situations or circumstances in which lapses could occur. image
26. Instruct the client to routinely use relaxation, cognitive restructuring, exposure, and problem-solving exposures as needed to address emergent worries, building them into his/her life as much as possible. image
27. Develop a “coping card” on which coping strategies and other important information (e.g., “Breathe deeply and relax,” “Challenge unrealistic worries,” “Use problem-solving”) are written for the client’s later use.  image
11. Utilize a paradoxical intervention technique to reduce the anxiety response. (28) 28. Develop a paradoxical intervention (see Ordeal Therapy by Haley) in which the client is encouraged to have the problem (e.g., anxiety) and then schedule that anxiety to occur at specific intervals each day (at a time of day/night when the client would be clearly wanting to do something else) in a specific way and for a defined length of time.
12. Complete a Cost Benefit Analysis of maintaining the anxiety. (29) 29. Ask the client to evaluate the costs and benefits of worries (e.g., complete the Cost Benefit Analysis exercise in Ten Days to Self-Esteem! by Burns) in which he/she lists the advantages and disadvantages of the negative thought, fear, or anxiety; process the completed assignment.
13. Identify the major life conflicts from the past and present that form the basis for present anxiety. (30, 31, 32) 30. Assist the client in becoming aware of key unresolved life conflicts and in starting to work toward their resolution.
31. Reinforce the client’s insights into the role of his/her past emotional pain and present anxiety.
32. Ask the client to develop and process a list of key past and present life conflicts that continue to cause worry.
14. Maintain involvement in work, family, and social activities. (33) 33. Support the client in following-through with work, family, and social activities rather than escaping or avoiding them to focus on panic.
15. Return for a follow-up session to track progress, reinforce gains, and problem-solve barriers. (34) 34. Schedule a “booster session” for the client for 1 to 3 months after therapy ends.
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DIAGNOSTIC SUGGESTIONS

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Notes

image indicates that the Objective/Intervention is consistent with those found in evidence-based treatments.