These
anxiety disorders differ from one another in the types of objects or situations
that induce anxiety, fear, or avoidance behaviour, and the associated cognitive
ideation (DSM-V). However, people often remain under-diagnosed and
under-treated. There were a lot of cases of people delaying in seeking
treatment such as ignorance of the condition, fear of taking medications, and
the stigma of receiving a psychiatric diagnosis, and or having to accept
psychiatric treatment. Treatment can be done either by pharmacotherapy,
psychotherapy or both combinations to anxiety disorder patients with the
decision made by the patient itself (Gould, Otto, Pollack, 1995). It is
important for anxiety disorder patient to seek treatment fast as they have an
earlier age of onset and hence a longer duration of ill-health (Greenberg,
Birnbaun, Sisitsky, 2004).
Assessments are important to screen
the patients to see whether they have psychiatric disorders or not before
proceed with interventions. Every anxiety disorders have different assessments.
To know whether a patient has panic disorder, clinical assessments that can be
used are the Panic Disorder Severity Scale (PDSS) and the Panic and Agoraphobic
Scale (PAS). Treatment response in panic disorder can be quantified and documented
with the Panic Disorder Severity Scale (Shear et al, 1997). PDSS is a
clinical-rated instrument assessing 7 dimensions of panic disorder on 4-point
scales and also available in a self-report version. The 7 dimensions divides to
7 items consists of panic frequency, distress during panic, panic-focused
anticipatory anxiety, phobic avoidance of situations, phobic avoidance of
physical sensations, impairment in work functioning, and impairment in social
functioning; and each rated on a 5-point scale, which ranges from 0-4. The
overall score is counted by summing the scores for all seven items and the
total scores range from 0 to 28. The PDSS-self report version is used as a
screening tool and a score of 9 and above suggests the need for a formal
diagnostic assessment.
In addition, PAS measures the
severity of illness in patients with panic disorder with or without agoraphobia
(Bandelow, 1999). With the assessment is available in both
clicician-administered and self-rating formats, it also contains 5 sub-scales
which consists of panic attacks, anticipatory anxiety, agoraphobic avoidance,
functional avoidance (health concerns) and disability. First, the respondents
are asked to read the definition of “panic attacks” and then rate the severity
of their symptoms over the past week.
Patients with a possibility of
generalised anxiety disorder can be tested by the Generalised Anxiety Disorder
7-item (GAD-7) scale (Spitzer et al, 2006). GAD-7 is a self-reported
questionnaire for screening and severity measuring of generalised anxiety
disorder. This assessment has 7 items that measure severity of various signs of
generalised anxiety disorder according
to reported response categories
of “not at all,” “several days,” “more than half the days,” and “nearly every
day.” The total score is obtained by adding the scores for all seven items and
the most scores shows the severity of GAD in a patient.
The Social Phobia Inventory (SPIN)
is a 17-item questionnaire to screen whether the patient have social phobia and
to know the level of severity in social phobia (Connor et al, 2000). Ways of
answer is by choosing between 5 categories which is “not at all,” “a little
bit,” “somewhat,” “very much” and “extremely”. Some of the 17 items are “I am
afraid of people at the authority”, “I avoid going to parties” and “I avoid of
giving speeches”. Item score are added to produce a total score. Higher score
indicates more severe symptoms. A cut-off value of 19 may be used to
distinguish between patients with and without social phobia. A very severe
score would exceed 51.
Post-traumatic stress disorder
patients can be assessed by using a short PTSD Rating Interview which is called
SPRINT for short (Connor & Davidson, 2001). The SPRINT provides a brief
global assessment for post-traumatic stress disorder and each of the individual
symptom clusters associated with the disorder such as intrusion and
re-experiencing, avoidance and numbing; and hyperarousal. The SPRINT is
responsive to symptom change over time and correlates with comparable symptom
measures. Trauma victim shows a score of 14-17 which is associated with 96%
diagnostic accuracy, whereas in those with post-traumatic stress disorder,
highest efficiency corresponded to a range of 11-13. A reliable, valid,
homogeneous measure of ptsd illness severity, global improvement and solid
psychometric properties best describes SPRINT.
Yale-Brown Obsessive Compulsive
Scale (Y-BCOS) is an ideal tool to rate the severity of obsessive-compulsive
disorder symptoms (Goodman, Price & Rasmussen, 1989). It is used frequently
for the purpose of clinical practice and in research to both determine severity
of the disorder and to monitor improvement during treatment. It measures
obsessions separately from compulsions, specifically measuring the severity of
symptoms of obsessive-compulsive disorder without being biased towards the type
of content of obsessions or compulsions present. The scale consists of 10
items, with each items rated from 0 (no symptoms) to 4 (extreme symptoms),
yielding a total possible score ranging from 0 to 40. The items includes the
amount of time the patient spends on obsessions, how much impairment or
distress they experience, and how much resistance and control they have over
these thoughts. The results can be interpreted at a lowest, a sub-clinical from
0 to 7 and the highest score, extreme from 32 to 40. Patients who scores above
15 are likely experience a significant negative impact on their quality of life
and should consider professional help in alleviating obsessive-compulsive
symptoms. This assessment is also self-rated.
5.0 Intervention
The
intervention of the patients with anxiety disorder can be started off by giving
options to the patients of psychological or pharmacological treatment. The
patients get to choose either one or both depends on their preference and
motivation, the skills and experience of the clinician, availability of
resources, response to prior treatment, and the presence of comorbidities
(Canadian Psychiatric Association, 2006). In general, in the psychological
treatment, the patient needs to receive education about their disorder, including
aetiology, treatment choices, and prognosis. Helpful reading materials such as
information brochures for anxiety condition, which contact details of agencies
catering counselling and the support of persons with psychiatric problems, are
recommended. Counselling is one of the choices that a patient can choose from.
In the counselling session, a good therapeutic relationship will be created,
with a fundamental agreement of goals and tasks of therapy and commitment to
the working relationship between therapist and patient. The duration,
frequency, and nature of treatment should be collaboratively agreed upon at the
outset. Social, cultural and religious or spiritual of the patient should be
respected by the therapist or counsellor.
Intervention through counselling for
panic disorder patients can be done with cognitive behaviour therapy. The goal
of the treatment is to eliminate panic attacks, anticipatory anxiety and
avoidance. First, the patient can be treated by giving psycho-education which
involves teaching patients about the disorder, discussing the treatment
options, modalities of treatment, and coping strategies. Psycho-education has
been shown to improve quality of life, reduce symptoms, and improve treatment
outcomes because it will give a strong understanding of the patient’s disorder
and learn how to change the patient’s thinking. The treatment components of
cognitive behaviour therapy may include psycho-education, in-vivo exposure to
feared situations, interceptive exposure, cognitive restructuring, continuous
panic monitoring and breathing retraining. Patients can also be benefitted and
develop well with the support of family members, friends, support groups and
voluntary organizations. Generalised anxiety disorder patients can also be
treated with counselling by using the same therapy, which is the cognitive
behaviour therapy (CBT). CBT may be used as first-line treatment for
generalised anxiety disorder than the treatment of pharmacotherapy. The
technique is the same as the panic disorder where psycho-education comes first.
It is important to make the patient understand the condition they are in and
the time that the patients understand, the counsellor restructures the
patient’s mind by thinking that the beliefs of the patient are not true about
certain event and produce insight from the client of the consequences for the
patient’s action and beliefs. Counselling every week gives enough time to the
patient to practice the restructuring cognitive thinking from the session. The
counsellor needs to keep asking the patient their update on a different belief
that the counsellor teach to the patient in counselling session and upgrade to
more challenging quest prior to the patient’s disorder. After everything is
complete, the counsellor needs to also educate the patient on relaxing such as
taking deep breaths and progressive muscle relaxation (PMR) for the patient to
practice outside of session.
Specific phobia patients can also go
through intervention with cognitive behaviour therapy (CBT). The goals of
treatment of specific phobia are the mastery of fear and the recovery of
function. Components of CBT for specific phobia may include systematic
desensitisation, imaginal exposure and in-vivo exposure. Systematic
desensitization is a behavioural technique whereby a person is gradually
exposed to an anxiety-producing object, event, or place while being engage in
some type of relaxation at the same time in order to reduce the symptoms of
anxiety. For example, a person has a phobia of cockroaches. Some people can be
very anxious when facing or countering with a cockroach. They will start
thinking and imagining a lot of things of the cockroaches until they refuse to
be near with it or touching it. Systematic desensitization technique starts by
practicing relaxation in the counselling session and next, is done by hierarchy
steps of ranked 1 to 10 of something that the patient is fearful of. After
that, the counsellor will start of by showing pictures or videos of it, bringing
a replica of it in the session, and touch it in the end. This technique
requires a lot of sessions because every steps cannot be done in just several
sessions. This technique has similarities with imaginal exposure and in vivo
exposure. Imaginal exposure is vividly imagining the feared object, situation,
or activity. For example, someone with phobias of cats might be asked to recall
and describe the patient’s experience in order to reduce the feelings of fear.
The counsellor will assist in the clients to see beyond the patient’s fear. In
vivo exposure is a technique that is directly facing a feared object,
situation, or activity in real life. For example, someone with a fear of snakes
might be instructed to handle a snake in the session. This is to let the
patient experience something that he or she is afraid of and this is assists by
the counsellor to reduce the fear. As much as 70-85% of specific phobias could
be effectively treated by exposure therapy (Park et al, 2001).
Social Anxiety Disorder patients can
be treated with counselling by giving exposure to feared situations in
cognitive behaviour therapy (CBT). Group counselling can be very helpful for
these patients as it gives them the chance to communicate to one another as a
practice before talking to other people outside the session. CBT interventions
include in-vivo exposure, cognitive restructuring, relaxation training and
self-control desensitisation, of which exposure-based interventions are the
most efficacious for social anxiety disorder (Borgeat et al, 2009). Cognitive
restructuring can be down by using the ABC method which is A= Activating event,
B= Belief and C= Consequences. Giving pscho-education to the patient on the
ABCs and making them understand that their belief is not true. Consequences can
change by thinking differently. Usually the patients will have this emotional
negative thinking towards an event and the consequences of that belief makes it
worse for the patient where it can effects their emotion and the situation to a
negative way.
Counselling can be a good treatment
for patients with a obsessive compulsive disorder (OCD). Cognitive behaviour
therapy (CBT) may be used as first-line treatment for OCD patients if patients
prefer psychological treatment over pharmacotherapy. CBT substantially reduces
OCD symptoms (Steward & Chambless, 2009). A primary tool in a form of CBT
treatment called exposure and response prevention (ERP) or exposure therapy.
This treatment helps the patient to make a list of exposure to the fears that the
patients has, starting with the least anxiety-provoking items from the list.
These list are practice in the counselling session with the assistance of the
counsellor and the patient will be given homework to practice it outside the
session before coming to the next session to discuss about it. Imaginal
exposure, a part of ERP is also frequently used in the treatment of OCD which
involves the patient to write short stories based on the client’s obsessions.
These stories makes the patient has a more clearly understanding of the
patients’ fearful thoughts. When combined with standard ERP, and other CBT
techniques, imaginal exposure stories can help to greatly reduce the frequency
and magnitude of these intrusive obsessions, as well as the individual’s sensitivity
to unwanted thoughts and mental images.
After assessing the patient’s level
of post-traumatic stress disorder (PTSD), there is a need for the patient to
undergo psychotherapy treatment. Evidence suggests that CBT is an effective
treatment for PTSD (Bisson & Andrew, 2007). The components of CBT include
prolonged exposure (PE) to memories of the traumatic event. Based on the
American Psychological Association, prolonged exposure teaches individuals to
gradually approach their trauma-related memories and cues are not dangerous and
do not need to be avoided. PE helps patient to confront their fears. The name
prolonged exposure explains that the patient need to have sessions with the
counsellor over a period of about 3 months, resulting in eight to 15 sessions
overall. The original intervention protocol was described as nine to 12
sessions, each 90 minutes in length (Foa & Rothbaum, 1998). Sixty to
120-minute sessions are usually needed in order for the individual to engage in
exposure and sufficiently process the experience. The counsellor begins with an
overview treatment and understanding the patient’s past experiences. Next, the
counsellor gives psycho-education and then will teach the patient the breathing
technique to manage anxiety. Generally,
after the assessment and initial session, exposure begins. As this is very
anxiety-provoking for most patients, the therapist works hard to ensure that
the therapy relationship is perceived to be a safe space for encountering very
scary stimuli. Both imaginal and in vivo exposure are utilized with the pace
dictated by the patient.
Imaginal exposure occurs in session
with the patient describing the event in detail in the present tense with
guidance from the therapist. Together, patient and therapist discuss and
process the emotion raised by the imaginal exposure in session. The patient is
recorded while describing the event so that she or he can listen to the
recording between sessions, further process the emotions and practice the
breathing techniques. In vivo exposure, that is confronting feared stimuli
outside of therapy, is assigned as homework. The therapist and patient together
identify a range of possible stimuli and situations connected to the traumatic
fear, such as specific places or people. They agree on which stimuli to
confront as part of in vivo exposure and devise a plan to do so between
sessions. The patient is encouraged to challenge him or herself but to do so in
a graduated fashion so as to experience some success in confronting feared
stimuli and coping with the associated emotion. This shows that CBT and
exposure therapy has a big impact on the intervention of the anxiety disorders.
