Introducing Cognitive Behavioural Therapy (Introducing...) (6 page)

Case study – Billy (panic disorder with agoraphobia)

Billy is a 25-year-old office-worker. He commutes daily using public transport. He used to like the train journey. It gave him time to read the paper and relax a little before the start of a stressful day. One day, however, the train was particularly crowded. It was very hot and the train’s air conditioning had failed. Billy started to feel very warm. He noticed that he was sweating and that his heart had started to race. His chest hurt and he felt shaky. He thought something must be very wrong. He was convinced he was having a heart attack. He got off the train at the next stop and called an ambulance. In A&E he was examined and told that there was nothing wrong with his heart. He had had a panic attack. He felt very relieved but shaken and frightened by what had happened. He had really felt like he was dying. He never wanted to feel like that again. The next time he went on the train he was very anxious and again started to notice symptoms. Again he focused on these and experienced the frightening feeling that he was dying. The sensations were very difficult to cope with and he was forced to get off the train and go home. Gradually, Billy found that his fear of the panic symptoms led to him avoiding more and more situations where he thought they might occur and where he was afraid he would not be able to escape.

Over time, Billy’s avoidance became more and more entrenched. He did not believe he could withstand or manage the panic symptoms and so he would simply not do anything that he felt might trigger them. He gave up his job and started to work from home. Slowly he went out less and less and his social life dwindled. As he avoided more situations, so his fear that a catastrophic attack would happen increased and he felt increasingly unable to go out at all.

Obsessive-compulsive disorder (OCD)

Obsessive-compulsive disorder (OCD)
consists of recurring obsessions, compulsions or both.

Obsessions
are recurring intrusive, uninvited and unwanted thoughts, images, or urges that cause you anxiety or disgust. Common obsessions are fears of being contaminated by dirt, germs, disease or body fluids, and also fears of disasters. They can encompass worries about violence that will happen to you, or harm you might do to others despite it being against your will, including paedophilia and bestiality. Fears related to religious beliefs are also common.

Compulsions
are thoughts or actions that you feel you
must
force yourself to have or do, and often that you feel you have to keep repeating, until you have got it ‘right’. Usually a compulsion is a response the person makes to ease the anxiety caused by an obsession. A common example is repeated hand washing in response to obsessive fear of dirt or germs. An individual may disproportionately fear that they have dangerous germs on their hands from touching things and that these could be harmful to themselves or people around them. They may therefore feel a compulsion to very frequently wash or disinfect their hands in order to reduce this fear. Other examples of compulsions include: repeated cleaning, checking, counting, touching, placing objects in particular positions and also hoarding objects.

Often professional help is required, as it can initially be quite difficult for a person to discriminate between obsessional thoughts and actual danger. Likewise, if you fear you are going to harm someone against your will, understandably you won’t be keen to put this to the test, just in case you were to find out it was indeed so.

People suffering from OCD often have an exaggerated sense of responsibility. They may feel it is their role to protect themselves from the dangers of the world, the threats of which they usually considerably overestimate. They may also feel they must ensure that harm does not come to others. Very often carrying out the ritual or compulsion still doesn’t solve the problem. They might experience intrusive thoughts about harm coming to others. So, for example, they may feel they have to move stones off pavements to avoid someone tripping but then go on to worry that the new place they have moved them to could cause harm to someone instead.

Health anxiety

Some concern about your health can be useful, as it means you may try to lead a healthier lifestyle. People who have had health problems, in particular something like a heart attack or cancer, often decide to take them as a warning that unless they make certain changes, then something worse could happen next time. While that attitude can be very productive for some, others find they become increasingly obsessed with their health. Some people find this increased anxiety happens to them following the illness of someone they know, after an important life change or just out of the blue for no obvious reason at all. Any minor symptom is blown out of all proportion. A minor sniffle equates to imminent death from swine flu, a mark on the skin means malignant cancer, tiredness is multiple sclerosis, while a headache equates to a brain tumour – which will, of course, be inoperable. People with health anxiety visit their doctor frequently and can end up having many investigations, tests and visits to specialists which often come to nothing. They may also spend a large amount of time researching illness on the internet and in books. The worry and fear of illness can take over people’s lives and cause considerable misery.

Case study – Mamta (health anxiety)

Mamta is a fit, healthy woman in her 50s. Tragically, one of her closest friends recently died of breast cancer. She had been a very healthy woman who took good care of herself, ate well and exercised regularly. Her cancer came out of the blue. She went through many months of distressing treatment before dying at the age of 53. Mamta is naturally very upset by this loss and also frightened by the way in which her friend suddenly became ill. She begins focusing on her own body and on anything she experiences which could be interpreted as a symptom of ill health. If she has a headache or a muscle twitch, or notices an ache anywhere in her body she becomes totally preoccupied with this, worrying endlessly about what it might mean. Mamta looks symptoms up on the internet, or asks others what they think is wrong with her. She visits her GP more frequently, asking for reassurance that what she sees as being symptoms aren’t signs of something serious. Having seen the doctor, Mamta feels better for a short while but then starts worrying again. Her GP sends her for several tests because Mamta is worrying about symptoms which previously she’d have ignored. As Mamta’s anxiety and stress increase, she experiences more physical symptoms related to anxiety – more frequent headaches, fatigue, palpitations and general aches and pains. These of course add to her worries and send her back to the GP and to other sources of reassurance. When her doctor assures her there’s nothing wrong, Mamta begins to doubt him and starts exploring an ever-increasing range of different types of therapies.

How CBT can help with anxiety

The good news is that there are lots of tried and tested techniques which have been developed by CBT therapists to help people overcome anxiety disorders. The following methods can all be applied to a variety of the disorders described above. Some will be more helpful in certain situations than others. Try them out and see which work for you. We will first look at how you might deal with your thoughts and will then move on to examine some behavioural strategies which may be helpful to manage your anxiety.

Thought balancing

This technique is key to cognitive therapy and involves looking at your anxious thoughts in a different way. You really can start to see that thoughts are just that, and do not necessarily represent facts. We can see thoughts as simply
mental events
. Yet frequently we respond to them as if they were concrete facts rather than possibilities or ideas. Just because you think something bad will happen is that guaranteed? Some thoughts will be true, some won’t and there will be a large grey area in between these two extremes. Remembering this is a good place to start.

Chapter 6
looks at depression and shows you how to begin to manage your negative thoughts by examining the objective evidence for them and working on developing alternative balanced (and ultimately more realistic and helpful) ways of viewing a situation. Check out some of the exercises there. Consider whether you are being affected by any of the distorted ways of thinking that we describe.

When dealing specifically with anxious thoughts, worries or predictions it can be helpful to ask yourself the following questions to help you gain a different, and potentially more helpful, perspective. Write down the answers for each of your separate worries or thoughts.

Our questions to challenge your worries or anxious thoughts

• How important will this be in my life 5 years from now?

• What would my best friend say I should do about it?

• What would I advise my best friend to do if this was their problem?

• Am I assuming my way of seeing things is the only one possible?

• Am I jumping three events ahead when the first step hasn’t even happened yet?

•Am I overestimating the chances of disaster?

Now think of some of your own questions to challenge your worried, anxious thoughts, and write them down. Feel free to write as many as you like!

Thoughts are not facts – however real and frightening they may
feel
.

Challenge perfectionism

Do you always expect more of yourself than it is possible to achieve? Do you have much higher standards for judging yourself than for other people? If this is true then you may be falling into self-defeating patterns that are maintaining your anxiety and making you very unhappy. Look at the section in
Chapter 6
which discusses how to reduce self-criticism.

Watch out for ‘should’, ‘always’ and ‘must’ in the way you talk to yourself – these words are rarely helpful. Jane from our case study frequently says to herself ‘I
should
be doing this perfectly’, and ‘I
must
get all this right first time all by myself or I’ll look a right idiot!’ These statements just make her feel miserable.

Try to stick to the rule ‘good enough is good enough’. You can still be good at things, but aiming for excellence rather than perfection is much more likely to get you results. Do you know anyone who is actually perfect in every way? No? So how come you expect yourself to be able to achieve this?