What is Generalised Anxiety disorder?
Individuals who suffer from generalised anxiety
disorder (GAD) experience unrealistic or
excessive worry about two or more life events.
Some of the following symptoms must be present
over a period of at least six months in order to
consider to consider this diagnosis.
Tension and tiredness
Hard to concentrate
shortness of breath
Many people with generalized anxiety disorder
describe themselves as chronic worriers, who
often become more upset by problems than the
average person. The key component is not worry,
but excessive worry.
Many people with generalized anxiety experience
a panic attack at some point in their lives, in
response to more severe stress. Eventually, the
person begins to worry about worrying. That is,
because you see yourself as an anxious person
who can't handle stress very well, you develop
additional anticipatory anxiety when you must
face a stressful situation (e.g. going for a job
interview, entering the hospital for a medical
Many primary care physicians treat generalized
anxiety disorder exclusively by prescribing anti-
anxiety medications, especially benzodiazepines,
rather than referring the person for
psychotherapy. However, these drugs are not
without risk. They cause impairment of cognitive
functioning, including reaction time. Many
individuals experience rebound anxiety if they
abruptly stop taking the medications. Research
has also suggested that the benzodiazepines may
produce functional changes in the central
nervous system that make it difficult for people
to withdraw from these drugs.
GAD is not a biological problem, it is a
psychological problem with pronounced physical
symptoms. It requires psychological treatment,
most often a combination of behavioural and
cognitive therapy. Silvia Buet has used cognitive
behavioural treatment effectively to teach
individuals how to reduce their anxiety by using
a wide range of techniques. A combination of
cognitive-behavioural interventions shows very
positive results, without the drawbacks of
medication. The development of cognitive coping
strategies for managing anxiety is particularly
effective for individuals with generalized anxiety
What is Panic Disorder?
Panic attacks are sudden and intense feelings of
fear accompanied by physical symptoms, such
as a pounding heart, shortness of breath,
tingling sensations, and dizziness or light-
headedness. They occur repeatedly and
unexpectedly in the absence of any external
Each year about one in 10 people experiences a
panic attack, but only about one in 75 people
has panic disorder. Panic disorder involves a
series of unexpected, "false alarm" panic attacks.
These unexpected panic attacks can interfere
with a person's emotional life, relationships, and
ability to work.
These periods of intense fear are referred to as
"panic attacks". Most people with panic disorder
also feel anxious about the possibility of having
another panic attack and avoid situations in
which they believe these attacks are likely to
occur. Anxiety about another attack, and the
avoidance it causes, can lead to disability in
Typically, a first panic attack seems to come "out
of the blue," occurring while a person is engaged
in some ordinary activity like driving a car or
walking to work. Suddenly, the person is struck
by a barrage of frightening and uncomfortable
symptoms. These symptoms often include terror,
racing or pounding heart, chest pains, dizziness,
fear of fainting, difficulty breathing, tingling or
numbness in the hands, flushes, sense of
unreality, fear of losing control, and fear of dying
or going mad. The symptoms usually last only a
few seconds, but may continue for several
minutes. However, in more severe cases, some
symptoms can be present for days.
Panic disorder may progress to a more advanced
state in which the person becomes afraid of
being in any place or situation where escape
might be difficult or help unavailable in the event
of a panic attack. This condition is called
agoraphobia. It affects about a third of all people
with panic disorder. Typically, people with
agoraphobia fear being in crowds, standing in
line, entering shopping malls, and riding in cars
or public transportation. Often, these people
restrict themselves to a "zone of safety" that may
include only the home or immediate
neighbourhood. Thus, the person with
agoraphobia typically leads a life of extreme
dependency as well as great discomfort.
In addition to worry about panic attacks,
individuals with Panic Disorder also report
constant or intermittent feelings of anxiety that
are not focused on any specific situation or
event. An individual's preoccupation with health
can become debilitating if other activities of the
individual's life are left unattended to. In cases
where the disorder is undiagnosed or
misdiagnosed, the belief that an undetected life-
threatening illness exists may lead to both
chronic debilitating anxiety and excessive visits
to health care facilities. Relationships may be
strained or marred by conflict as panic attacks,
or the fear of them, rule the affected person and
those close to them.
TREATMENT OF PANIC ATTACKS
Several effective treatments have been developed
for panic disorder and agoraphobia. A form of
psychotherapy called rational emotive
behavioural therapy has been found to be
effective in the treatment of panic disorder.
EMDR (Eye Movement Desensitation
Reprocessing) could also be of benefit.
Medication can be used to prevent panic attacks
and also to reduce their frequency and severity,
and to decrease the associated anticipatory
anxiety. When individuals find that their panic
attacks are less frequent and severe, they are
increasingly able to venture into situations that
had been off-limits to them. In this way, they
benefit from exposure to previously feared
situations as well as from the medication.
Cognitive Behavioural therapy includes learning
about panic attacks and their causes, and
correcting the thoughts that cause panic attacks.
This treatment has been shown to be highly
effective at reducing panic attacks, with
approximately 80 percent of those going through
these treatments being panic-free at the end of
treatment. The person is expected to participate
in difficult and uncomfortable activities. Work
outside of the therapy sessions is required to
master new skills.
REBT consists of the following components, each
which will be described briefly: 1- Education, 2-
Cognitive Restructuring, 3- Breathing Training,
4- Relaxation Exercises, 5- Situational Exposure,
6- Interceptive Exposure. Each component is
aimed at alleviating panic attacks, agoraphobic
avoidance, chronic anxiety, and depression
associated with panic disorder (note: clinician's
may apply only those techniques that they
determine are relevant to your problem).
Throughout treatment, clients are educated
about panic attacks and the development of
panic disorder. An understanding of panic
disorder is believed to be an important part of
the recovery process.
Cognitive restructuring, a major part of the
treatment, is intended to correct distorted
thinking about panic attacks. The goal is to have
patients change their reaction to their emotional
arousal and panic symptoms, and learn to deal
effectively with anxiety provoking situations.
During the early sessions of therapy, patients are
asked to self-monitor their thoughts,
assumptions, and beliefs during anxiety
provoking situations and panic attacks. With the
collaboration of the therapist, patients begin to
appreciate the role of cognition, beliefs, and
appraisals in the evocation or accentuation of
anxiety and panic attacks. During the later
sessions, patients are taught to re-evaluate the
validity of these distorted thoughts, and change
them to more rational, adaptive ones. In
particular, patients' "catastrophic
misinterpretations" of panic-related somatic cues
-- the belief that these physical sensations are a
sign that he or she is dying at that moment -- are
addressed. Patients will repeatedly challenge
their dysfunctional thoughts during treatment.
Breathing training teaches clients a pattern of
slow, regular breathing which prevents
hyperventilation, an uncomfortable symptom of
and cue for panic attacks.
Relaxation exercises that involve progressive
muscle tension are often incorporated to lower
general anxiety levels.
Situational exposure consists of structured and
repeated exposure to anxiety - and panic
provoking ("phobic") situations. Based on the
patient's individualized list of feared situations,
he or she undergoes exposure to these situations
while using coping strategies learned during
therapy, beginning with the least feared and
moving to the most feared. This typically takes
place later on during therapy, once a patient
feels more in control of panic attacks. The aim of
situational exposure is to eliminate agoraphobia.
When necessary, Interceptive exposure may be
conducted. Interceptive exposure involves the
structured and repeated exposure to panic-like
physical sensations. Based on the patient's
individualized hierarchy of feared internal
sensations (e.g., dizziness, palpitations), he or
she undergoes systematic exposure to these
sensations. The feared sensations may be
produced using idiosyncratic methods such as
controlled hyperventilation or physical exertion
(e.g., running up a flight of stairs to get your
heart racing). This is necessary because patient's
often become fearful of harmless body
sensations, such as those caused by exercise,
caffeine, and excitement.
IS THIS TREATMENT FOR YOU?
As it may appear, the treatment requires a fair
amount of work. Therefore, I encourage patients
to enter only when they feel committed to
overcoming their problem. Practicing what is
covered during therapy sessions at home is
essential to getting better.
You may feel that the treatment itself is anxiety
provoking. After all, why would you want to go
into situations which make you feel anxious? In
my opinion, as well as many other clinicians and
researchers in this field, one must confront
his/her anxiety to get over it. However, please be
assured that patients move at a rate at which
they feel comfortable. Clients are given
encouragement by the therapist to overcome this
problem, but no one is pushed into doing
something he or she is not ready for. The
therapist understands the intense fear involved
in this problem. The goal of the therapist is to
prepare the client to deal with each step in an
effective manner using the techniques described
above. The client and therapist maintain a
friendly, collaborative relationship. The therapy
focuses on the present problem and how to
alleviate it. If you are ready to make the
commitment, and the treatment sounds sensible
to you, then there is no reason to believe you can
not get better.
People who experience panic and agoraphobia,
are not "crazy" and do not need to be in therapy
for extended periods of time. Sessions depend on
the severity and length of the problem and the
willingness of the client to actively participate in
treatment. On average, 16 sessions are normally
What is Depression?
Depression is a mood disorder that is brought on by
overly negative inferences, interpretations and irrational
beliefs about ourselves, others or/and the events in our
Why do we get depressed?
Dysfunctional thinking is largely what causes
depression. According to Cognitive theory, we do not
get disturbed just because we encounter a negative
event, we need to interpret and/or evaluate that
situation in a very negative and distorted manner in
order to feel depressed. Therefore, events are
considered the ones triggering the irrational beliefs we
may hold, while those irrational beliefs are in fact the
ones causing the depression.
There other TRIGGERS why a person may feel
depressed such as having a physical illness, biological
changes, the loss a significant person, a break-up or
separation, poor health, etc.
If events caused directly depression, then everyone
would get depressed about the same things and their
distress would be identical from one individual to
another. In reality, people get unhealthily disturbed and
depressed only when they have a number of irrational
beliefs about the event/s. Rational Emotive Behavioural
therapy can be quite effective to identify and modify
those types of beliefs. Sometimes, it is just not possible
to make a positive change to something that happened
in the past. Therefore, when we cannot do anything
about changing what is triggering our depression, we
still can learn to change our beliefs about the event and
by doing so, we will feel more in control and coping
better. However, sometimes we can change the
situation by just behaving differently, when this is the
case REBT, would focus on developing the necessary
coping mechanisms or social skills.
Depression can also be more than the problem itself, a
consequence of some other problem. Normally, people
suffering from panic attacks feel so limited and for so
long that eventually, they develop depression. So,
anxiety can be one of the main causes of depression.
Guilt and shame are also very common triggers of
depression, for example if you feel guilty and cannot
know how to accept yourself and your mistakes, you
may feel depressed too. Sometimes, when this is what
happens, we assess what we need to work on first.
In summary, What Rational Emotive Behavioural
therapy does is to identify that combination of
inferences, interpretations, irrational beliefs and
dysfunctional personal rules causing the depression.
Once identified, client and therapist work towards
challenging those beliefs in order to find a more
realistic, functional way of thinking.
Just "thinking positively" is not going to decrease
depression in any lasting way. Though depressed
people do not engage in a great deal of positive
thinking, it is not just the absence of positive thoughts
but the frequency of negative thoughts and the
dysfunctional patterns of thinking that perpetuate
depressed mood. Advice to "think positively!" or to
engage in "positive affirmations" like "I'm a good
person" often does not work. Positive thinking alone will
not alleviate depression. Saying "I'm doing a great job"
will not work when for the majority of the day, your
automatic thoughts are self-critical and hopeless.
Therefore, even though you are telling yourself positive
things, you still believe negative things.
DSM IV Criteria for Major Depressive Episode
A. At least one of the following three abnormal moods which
significantly interfered with the person's life:
1. Abnormal depressed mood most of the day, nearly
every day, for at least 2 weeks.
2. Abnormal loss of all interest and pleasure most of the
day, nearly every day, for at least 2 weeks.
3. If 18 or younger, abnormal irritable mood most of
the day, nearly every day, for at least 2 weeks.
B. At least five of the following symptoms have been present
during the same 2 week depressed period.
1. Abnormal depressed mood (or irritable mood if a
child or adolescent) [as defined in criterion A].
2. Abnormal loss of all interest and pleasure [as defined
in criterion A2].
3. Appetite or weight disturbance, either:
Abnormal weight loss (when not dieting) or
decrease in appetite.
Abnormal weight gain or increase in appetite.
4. Sleep disturbance, either abnormal insomnia or
5. Activity disturbance, either abnormal agitation or
abnormal slowing (observable by others).
6. Abnormal fatigue or loss of energy.
7. Abnormal self-reproach or inappropriate guilt.
8. Abnormal poor concentration or indecisiveness.
9. Abnormal morbid thoughts of death (not just fear of
dying) or suicide.
C. The symptoms are not due to a mood-incongruent
D. There has never been a Manic Episode, a Mixed Episode,
or a Hippomanic Episode.
E. The symptoms are not due to physical illness, alcohol,
medication, or street drugs.
F. The symptoms are not due to normal bereavement.
Associated Features and Comorbidity
o 80 to 90% of individuals with Major Depressive
Disorder also have anxiety symptoms (e.g., anxiety,
obsessive preoccupations, panic attacks, phobias, and
excessive health concerns).
o Separation anxiety may be prominent in children.
o About one third of individuals with Major
Depressive Disorder also have a full-blown anxiety
disorder (usually either Panic Disorder, Obsessive-
Compulsive Disorder, or Social Phobia).
o Anxiety in a person with major depression leads to a
poorer response to treatment, poorer social and work
function, greater likelihood of chronicity and an
increased risk of suicidal behaviour.
o Individuals with Anorexia Nervosa and Bulimia
Nervosa often develop Major Depressive Disorder.
o Mood congruent delusions or hallucinations may
accompany severe Major Depressive Disorder.
o The combination of Major Depressive Disorder and
substance abuse is common (especially Alcohol and
o Alcohol or street drugs are often mistakenly used as
a remedy for depression. However, this abuse of
alcohol or street drugs actually worsens Major
o Depression may also be a consequence of drug or
alcohol withdrawal and is commonly seen after
cocaine and amphetamine use.
o 25% of individuals with severe, chronic medical
illness (e.g., diabetes, myocardial infarction,
carcinomas, stroke) develop depression.
o About 5% of individuals initially diagnosed as
having Major Depressive Disorder subsequently are
found to have another medical illness which was the
cause of their depression.
o Medical conditions often causing depression are:
Endocrine disorders: hypothyroidism,
hyperparathyroidism, Cushing's disease, and
Neurological disorders: multiple sclerosis,
Parkinson's disease, migraine, various forms of
epilepsy, encephalitis, brain tumours.
Medications: many medications can cause
depression, especially antihypertensive agents
such as calcium channel blockers, beta
blockers, analgesics and some anti-migraine
If you want to read more about depression and how to
identify and modify your dysfunctional beliefs, click on this
link: "Coping with Depression" (Beck & Greenberg).
What is anger?
Anger is an intense emotion that most of us feel
from time to time. Suppressing anger is not the
answer nor is the full expression of it because
both extremes can lead to very undesirable
outcomes. With Rational Emotive Behaviour
Therapy you can learn to be to deal with your
anger in a constructive manner without
suppressing or venting it.
What causes anger?
If you want a short answer, it is you, nothing or
nobody else but you. How is this possible?
OK, let’s imagine a situation. The situation will
be that someone calls you “selfish”. If you think
of a few people, I am sure that you will say that
not everyone of them, would be angry if they
were called “selfish”, some would feel angry,
others hurt, others ashamed, others guilty and
some others, even depressed.
Therefore, if you agree that people react
differently in a specific situation, then you are
saying that not everyone perceives that situation
in the same way. That difference in our
perception depends on our beliefs, inferences
and interpretations we have learnt from past
experiences. Events do not CAUSE our anger
feelings but our particular way to perceive those
Let me give you an example of what people may
think to make them feel the above-mentioned
range of emotions when they are called selfish.
You will see than depending on what we belief
about the activating event, we feel either guilty/
depressed or angry.
Activating event Beliefs
I shouldn’t be this
selfish. I always let
Someone Guilt and
people down. I
calls me depression
always do the
wrong thing, what
a horrible person I
Me selfish? I am Angry
Someone not selfish and you
calls me shouldn't think
selfish like that. I don't
deserve to be
because it's not
true, I cannot bear
that of me and you
are worse than me,
With this example, you will see that the person
feeling guilty and depressed is talking to herself
in a very different way to the person feeling
angry. That is because we perceive the situation
according to our beliefs. Those beliefs are mainly
the CAUSE of our anger and not the activating
If the activating event were what makes you
angry, then your only choice you would have,
would be to change the situation/other person
in order to stop your anger feelings. However,
you still have the choice to change your anger,
say into annoyance, if you are able to assume
the responsibility that you are the owner of your
feelings. If you believe then, that is you making
yourself angry, then you can actually do
something with those feelings instead of
depending on changing the situation to feel OK.
In therapy, you will learn that you have a
CHOICE to feel differently (remember our feelings
are largely caused by the way we perceive the
event) by changing those dysfunctional beliefs
CAUSING your anger.
Ideally, in a situation like that, feeling
disappointed and annoyed would be much
healthier than feeling angry, hurt, guilty or
A person can change the way he thinks and
hence, the way he feels by changing his
irrational beliefs about the situation that triggers
You can imagine the emotional impact the same
situation would have for a person in the same
situation as before but if his beliefs were as
Activating event Beliefs
It would have been
preferable if he
hadn’t told me
that, but there is
no reason why he
Someone calls Annoyed
me selfish and
his opinion. At the
end of the day, I
don’t have to agree
with it. Also I don’t
he means by being
selfish. I will ask
him if he can give
me examples and
see if we can put
That he tells me
that I am selfish is
not pleasant and
by no means, it’s
the end of the
world, I can cope
disapproving of me
and I’ll survive.
In REBT, anger management will focus on
identifying and modifying those irrational beliefs
CAUSING your anger and also develop some
strategies to be able to communicate your anger
in an appropriate and respectful way, learn to
become more assertive and control your anxiety
if that is one of the factors contributing to you
feeling more angry at times.
Anger management is very effective (once you
recognise that you make yourself angry and you
are willing to change some of your beliefs and
behaviours). 6 to 12 sessions may be enough to
transform your unhealthy anger into healthier
annoyance and disappointment. You are
expected to do some homework outside the
sessions to practice what you have learned.
What is Post Traumatic Stress
Post traumatic stress is an anxiety disorder that
occurs as a result of either being involved in or
being witness to a major traumatic event. It is a
common but often a misunderstood condition.
The essential element of PTSD, is that a person
either experienced or observed an event which
involved actual or threatened death or serious
injury to self or someone else. Any number of
traumatic events can cause PTSD, including
serious accidents, natural disaster, violent
attacks (e.g., mugging, rape, physical abuse,
terrorists attacks or being held captive), or
simply witnessing any of these events happen to
What are the symptoms of PTSD?
Symptoms associated with PTSD include,
1) Re-experiencing the event in varying sensory
2) Hyper-arousal in the Autonomic Nervous
3) Avoiding reminders associated with the
1) The re-experiencing of the trauma in at least
one of the following ways:
1. Recurrent and intrusive recollections of the
2. Recurrent distressing dreams of the event.
3. Sudden acting or feeling as if the event were
recurring e.g. "flashback" episodes,
4. Intense psychological distress at exposure to
events that symbolise or resemble an aspect
of the traumatic event.
5. A numbing of responsiveness or reduced
involvement in the external world some time
after the trauma, indicated by:
6. Diminished interest in activities and/or
7. Feelings of detachment or estrangement
from others and/or having a constricted
effect e.g. unable to have loving feelings or to
2) Persistent symptoms of increased arousal (not
present before the trauma) as indicated by two or
more of the following:
8. Hyper-alertness or being easily startled.
9. Sleep problems.
10. Guilt about surviving or behaviour
required to survive.
11. Problems with memory or concentration.
12. Avoidance of activities that arouse
13. Intensification of symptoms if events
symbolise or resemble the traumatic event.
3) Persistent avoidance of a stimuli associated
with the trauma and numbing of general
responsiveness (not present before the trauma),
as indicated by three or (or more) of the
14. Efforts to avoid thoughts, feelings, or
conversations associated with the trauma.
15. Efforts to avoid activities, places, or
people that arouse recollections of the
16. Inability to recall an important aspect of
17. Markedly diminished interest or
participation in significant activities.
18. Feeling of detachment or estrangement
19. Restricted range of affect.
20. Sense of a fore shortened future.
PTSD is present when these symptoms last more
than one month and are combined with loss of
function in areas such as job or social
relationships (APA 1994).
If you are experiencing some of the following
symptoms, you may be suffering from Post-
Traumatic Stress Disorder and when these
reactions persist it is necessary for the sufferer
to seek expert help in order to cope with the
It is common for someone who has a suffer a
trauma to develop other psychological problems,
Obsessive Compulsive Disorder e.g. checking
in order to make sure the place is safe,
Substance and alcohol abuse
Diagnostic and Statistical Manual of Mental
Disorders. Vol. IV American Psychiatric
How can PTSD be treated?
1. Cognitive-behavioural therapy, specifically
REBT is very effective in treating post traumatic
Stress disorder. Cognitive Therapy is involved in
identifying and modifying those thinking
patterns that may help alter the recollections of
the trauma and the feelings associated with the
Treatment for PTSD typically begins with a
detailed evaluation, and development of a
treatment plan that meets the unique needs of
the survivor. Generally, PTSD-specific-treatment
is begun only when the person is safely removed
from a crisis situation. For instance, if currently
exposed to trauma (such as by ongoing domestic
or community violence, abuse, or homelessness),
severely depressed or suicidal, experiencing
extreme panic or disorganized thinking, or in
need of drug or alcohol detoxification, addressing
these crisis problems becomes part of the first
Cognitive Behavioural Therapy will also be
Educating trauma survivors about how
persons get PTSD, how PTSD affects
survivors and their loved ones, and other
problems that commonly come along with
PTSD symptoms. Understanding that PTSD
is a medically recognized anxiety disorder
that occurs in normal individuals under
extremely stressful conditions is essential
for effective treatment.
Exposure to the event via imagery allows the
survivor to re-experience the event in a safe,
controlled environment, while also carefully
examining their reactions and beliefs in
relation to that event.
Examining and resolving strong feelings
such as anger, shame, or guilt, which are
common among survivors of trauma.
Teaching the survivor to cope with post-
traumatic memories, reminders, reactions,
and feelings without becoming overwhelmed
or emotionally numb. Trauma memories
usually do not go away entirely as a result of
therapy, but become manageable with new
Exposure therapy, is one form of CBT unique to
trauma treatment which uses careful, repeated,
detailed imagining of the trauma (exposure) in a
safe, controlled context, to help the survivor face
and gain control of the fear and distress that was
overwhelming in the trauma. In some cases,
trauma memories or reminders can be
confronted all at once ("flooding"). For other
individuals or traumas it is preferable to work
gradually up to the most severe trauma by using
relaxation techniques and either starting with
less upsetting life stresses or by taking the
trauma one piece at a time ("desensitization").
Along with exposure, CBT for trauma includes
learning skills for coping with anxiety (such as
breathing retraining, relaxation and grounding
techniques) and negative thoughts ("cognitive
restructuring"), managing anger, preparing for
stress reactions ("stress inoculation"), handling
future trauma symptoms, as well as addressing
urges to use alcohol or drugs when they occur
("relapse prevention"), and communicating and
relating effectively with people ("social skills" or
2. Pharmacotherapy (medication) can reduce
the anxiety, depression, and insomnia often
experienced with PTSD, and in some cases may
help relieve the distress and emotional
numbness caused by trauma memories. Several
kinds of antidepressant drugs have achieved
improvement in most (but not all) clinical trials,
and some other classes of drugs have shown
promise. At this time no particular drug has
emerged as a definitive treatment for PTSD,
although medication is clearly useful for the
symptom relief that makes it possible for
survivors to participate in psychotherapy.
3. Eye Movement Desensitization and
Reprocessing (EMDR) is a relatively new
treatment of traumatic memories which involves
elements of exposure therapy and cognitive
behavioural therapy, combined with techniques
(eye movements, hand taps, sounds) which
create an alteration of attention back and forth
across the person's midline. The effectiveness of
this technique for single traumas is very high
and results can be obtained in short period of
time. If you want to know more about this
therapy click here.
Silvia Buet has extensive experience in dealing
with traumas and cases and is also a Level II
qualified EMDR practitioner. You can contact her
by email or phone (02890 586361) if you require
further information or you wish you make an
What is Obsessive Compulsive
Obsessive Compulsive Disorder (OCD) is an
anxiety disorder. The presence of obsessions is
one of the essential features of OCD, the other
component is the compulsions.
We call obsessions to thoughts, images or
impulses, which are intrusive, unwanted and
Obsessional thoughts have the following
the thoughts must be recognised by the
sufferer as their own,
they often cant be resisted, even though the
subject feels compelled to try and push
them out of their mind
the thoughts are usually unpleasant and
the thoughts are repetitive .
Common thoughts include:
Contamination - e.g. My hands or my
clothes are dirty
Pathologic doubt - e.g. Did I close the front
Need for symmetry - e.g.. I must put that
ornament in the right place
Aggressive impulse - e.g.. I feel compelled to
hurt my baby
Sexual impulse - e.g.. I feel like saying
something inappropriate to that person
Most sufferers experience a mixture of such
thoughts. People can sometimes be preoccupied
by images rather than thoughts these are often
of a violent or sexual nature.
Compulsions are defined as:
1. repetitive behaviours (e.g., hand washing,
ordering, checking, need to ask or confess,
symmetry, hoarding, striving for perfection) or
mental acts (e.g., praying, counting, repeating
words silently) that the person feels driven to
perform in response to an obsession, or
according to rules that must be applied rigidly.
2. the behaviours or mental acts are aimed at
preventing or reducing distress or preventing
some dreaded event or situation; however, these
behaviours or mental acts either are not
connected in a realistic way with what they are
designed to neutralize or prevent or are clearly
3. At some point during the course of the
disorder, the person has recognized that the
obsessions or compulsions are excessive or
unreasonable. Note: This does not apply to
4. The obsessions or compulsions cause marked
distress, are time consuming (take more than 1
hour a day), or significantly interfere with the
person's normal routine, occupational (or
academic) functioning, or usual social activities
Rituals such as hand washing, counting,
checking, or cleaning are often performed in
hope of preventing obsessive thoughts or making
them go away. Performing these rituals, however,
provides only temporary relief, and not
performing them markedly increases anxiety.
Left untreated, obsessions and the need to
perform rituals can take over a person’s life.
OCD is often a chronic, relapsing illness.
Studies suggest lifetime prevalence is 2-3%. Peak
age for onset in women is between 24-35 and
later in men.
What Causes OCD and how to treat it?
There is growing evidence that OCD has a
neurobiological basis but also environmental
factors affect the development of the disorder.
Therefore, OCD improves with drug therapy.
Several medications have been proved effective in
helping people with OCD: sertraline,
clomipramine, fluoxetine, fluvoxamine and
paroxetine. However, a combination of drugs and
Cognitive Behavioural Therapy ease the distress
and shows the person how to deal with the
obsessions and compulsions in order to be less
A type of behavioural therapy known as
“exposure and response prevention” is very
useful for treating OCD. In this approach, a
person is deliberately and voluntarily exposed to
whatever triggers the obsessive thoughts and
then, is taught techniques to avoid performing
the compulsive rituals and to deal with the
anxiety. That is why the treatment of OCD can
be a little uncomfortable, therefore before
undergoing therapy is advisable that you can
prepare yourself mentally to cope with a bit of
discomfort at times or exposure cannot be
possible even at lower levels of anxiety. For
example, a compulsive hand washer may be
urged to touch an object believed to be
contaminated, and then may be denied the
opportunity to wash for several hours. The
treatment can also be time consuming because
some of the tasks required to do at home can
take up to 1 hour a day. Commitment and
motivation are necessary components for the
therapy to be effective.
OCD is sometimes accompanied by depression,
post-traumatic stress disorder, eating disorders,
substance abuse, or other anxiety disorders.
When a person also has other disorders, OCD is
often more difficult to diagnose and treat.
Relationship and break-up problems are one of
the most common issues that make people to
seek therapy and that is because relationships
play an very important role in our lives.
Cognitive Behavioural therapy is not only very
effective to deal with couples difficulties but also
to help individuals who are suffering or have
suffered emotional distress because of a
relationship. Individual therapy and help can
be offered for the following issues:
Dilemmas about either stay or leave a
Trying to let go and move on after a
Not having enough confidence to meet or
develop relationships with the opposite sex
e.g. due to assertiveness problems or
deficient dating skills.
Difficulty in maintaining and develop
intimate relationships e.g. problems
tolerating other partner’s flaws, infatuation,
fear of commitment…
Guilt and anger problems (abortion, affairs,
On the other hand, couples can find that
Cognitive Behavioural therapy, particularly
Rational Emotive Behavioural therapy is solution
focused oriented and addresses their main
difficulties in a brief period of time. Therapy is
designed to assist heterosexual or homosexual
couples with their relationship problems. It can
be used to gain more insight into each other, to
learn new and more effective ways of
communication, and to learn how to solve
Relationship problems that can be resolved in
therapy are varied. The following list represents
only a sample of some of the issues that can be
Communication difficulties leading to
arguments and conflicts
Intimacy or sexual problems
Anger problems and domestic violence
Loss of interest for the other partner
Separation and divorce counselling
fighting and criticizing
Family problems and disagreements
Thoughts of divorce
During the first and second session of Cognitive
Behavioural Therapy (REBT), the psychologist
will help you and your partner identify the
conflict issues within your relationship, and will
help you decide what behavioural or cognitive
changes (perceptions, inferences or
interpretations) are needed in order to feel
satisfied with the relationship again.
These changes may be different ways of
interacting within the relationship, or they may
be individual changes related to personal
psychological problems. Couples therapy
involves learning how to communicate more
effectively, and how to listen more closely.
Sometimes the process is very similar to
individual psychotherapy, sometimes it is more
like mediation, and sometimes it is educational.
The combination of these three components is
what makes it effective. Some homework will be
assigned at the end of every session to allow you
to practice the new skills or strategies you learn
during the session.
For those that choose divorce, therapy is also
available. However, contrary to common belief,
dissolution rarely ends the relationship. This is
especially true when children are involved.
Rather, dissolution is often a long and painful
process involving individual growth. Couples that
are committed to create a new relationship as
friends and co-parents will find their
transformation less painful and more
constructive for all concerned.
Silvia Buet offers down-to-earth help for
struggling couples, families, individuals. Highly
confidential, objective, non-judgmental and
accessible counselling. Conveniently located in
Belfast to only 5 minutes from City Centre, close
to Ormeau Park. Call 02890 586361 for more
information, or send e-mail.
What is Social Anxiety?
Social anxiety is the fear of social situations and
the interaction with other people that can
automatically bring on feelings of self-
consciousness, judgment, evaluation, and
Put another way, social anxiety is the fear and
anxiety of being judged and evaluated negatively
by other people, leading to feelings of
inadequacy, embarrassment, humiliation, and
The anxiety becomes worse when the person
fears that they are going to be singled out,
ridiculed, criticized, embarrassed, or belittled.
On occasions, the anxiety is so high that panic
attacks develop in response to some specific
social event (e.g. giving a speech).
People with social anxiety realize that their fear
is exaggerated, but they still cannot control it.
They tend to avoid situations in which they need
to perform in front of others, and this tends to
interfere with life adjustment in some way. As
you would expect, people with social anxiety
disorder have an elevated rate of relationship
difficulties and substance abuse. They also feel
their self-worth is low, feel inadequate and have
difficulty being assertive.
As many as 10 percent of the population may
experience social anxiety to some degree,
although they all do not seek treatment. Many
people are fearful of public speaking, but manage
to avoid it and cope well within a slightly more
limited life sphere. Some individuals have more
severe social anxiety, and are even fearful of
talking to strangers in any capacity. These
people have more serious adjustment problems,
and are more likely to seek treatment. Social
anxiety tends to develop during teen years, but
often in children described as excessively shy.
Symptoms of Social Anxiety Disorder
Physical symptoms often accompany the intense
anxiety of social phobia and include blushing,
profuse sweating, palpitations, intense fear, dry
mouth, panic attacks, trembling, and other
symptoms of anxiety, including difficulty talking
and nausea or other stomach discomfort. These
visible symptoms heighten the fear of
disapproval and the symptoms themselves can
become an additional focus of fear. Fear of
symptoms can create a vicious cycle: as people
with social phobia worry about experiencing the
symptoms, the greater their chances of
developing the symptoms.
People with social anxiety disorder usually
experience significant emotional distress in the
Being introduced to other people
Being teased or criticized
Being the centre of attention
Being watched while doing something
Meeting people in authority ("important
Most social encounters, especially with
Going around the room (or table) in a circle
and having to say something
Fear of using public bathrooms or writing in
Interpersonal relationships, whether
friendships or romantic
This list is certainly not a complete list of
symptoms -- other feelings have been associated
with social anxiety as well.
Treatment of Social Phobia
1. Cognitive Behavioural Therapy (CBT and REBT)
In repeated trials, sponsored by the National
Institutes of Mental Health, cognitive-
behavioural therapy has proven the most
effective treatment for social phobia.
Rational Emotive Behavioural Therapy (REBT)
helps people deal with anxious situations. It
involves understanding the problem and
developing coping strategies such as changing
thinking patterns in social situations, learning to
focus attention on effective social behaviours.
CBT usually begins with a study of the disorder,
examining the situations that provoke the
anxiety and the accompanying somatic
symptoms. This educational process sets the
understanding for training in skills to alleviate
and eventually conquer social phobia. These
skills include assertiveness training, relaxation
techniques, diaphragmatic breathing, the
cognitive restructuring of distorted and negative
thinking that contribute to social anxiety, and a
programmatic hierarchical exposure to situations
that precipitate anxiety.
Recent research indicates that approximately
70% of people who complete a short term
treatment program (10 to 15 sessions) are judged
to be much or very much improved. The amount
of improvement appears to be related to the
amount of time and energy the person devotes to
developing new coping strategies.
Combining pharmacotherapy with cognitive-
behavioural strategies is usually the most
SSRIs such as paroxetine, 20-40 mg/day (FDA
approved for the treatment of social anxiety
disorder), sertraline 50-100 mg/day, or
citalopram 20-40 mg/day are first line
medications for social phobia.
Benzodiazepines, such as clonazepam (Klonopin)
0.5 - 2 mg per day may be used if SSRIs are
ineffective or in combination with SSRIs during
the early phase of treatment before the SSRI
takes full effect. Benzodiazepines may be used on
a PRN basis especially in patients with non-
generalized social phobia that is limited to
Social phobia with performance anxiety, such as
public speaking, responds well to beta- blockers.
The effective dosage can be very low, such as 10-
20 mg of propranolol. It may also be used on a
prn basis; 20-40 mg given 30-60 minutes prior
to the anxiety provoking event. A "test dose" trial
should be given several days prior to the
Monoamine oxidase inhibitors such as
phenelzine also have significant efficacy in
treating the anxiety associated with social
phobia, but concerns regarding dietary
restrictions and potential for hypertensive crisis
prevents significant usage.
Silvia Buet provides psychological treatment for
social anxiety, using techniques appropriate to
the presenting symptoms. This depends what
triggers the anxiety, whether the individual has
panic attacks, and the severity of the symptoms.
Most often a combination of behavioural
interventions is used with cognitive therapy. The
behavioural treatment may include relaxation
training and systematic desensitization, as well
as flooding. Cognitive therapy helps you to
develop cognitive blocking mechanisms when the
anxiety begins to build, and also helps you
understand why the social anxiety symptoms
occur. This allows you to develop different ways
of coping by changing the way you perceive the
social situations triggering your anxiety.
American Psychiatric Association: Diagnostic
and Statistical Manual of Mental Disorders,
Fourth Edition. Washington, DC, American
Psychiatric Association, 1994.
Hidalgo, R.B., Barnett, S.D., and Davidson,
J.R.T. Social Anxiety Disorder in Review: Two
Decades of Progress. Int J of Neuropsychopharm
2001, 4, 279-298.
Kaplan H, Sadock B. Kaplan & Sadock's
Comprehensive Textbook of Psychiatry. Seventh
Edition, Baltimore, Williams & Wilkins, 1999.
Pollack M.H. Co-morbidity, neurobiology, and
pharmacotherapy of social anxiety disorder. J
Clin Psychiatry 2001;62 Suppl 12:24-9
Many people have difficulty speaking up in
conflict situations. Others may feel intimidated
by pushy people, or have low self-esteem and
regularly put aside their own desires in favour of
what others want. This can result in a variety of
psychological problems, especially depression,
with feelings of low self-esteem and helplessness.
Lack of assertiveness makes you feel powerless.
Psychologists use assertiveness training, which is
a behavioural technique, combined with
traditional psychotherapy, to help you develop
the necessary social skills to manage
interpersonal situations more effectively, and to
feel better about yourself in those interpersonal
situations. In particular, assertiveness training
teaches you how to refuse unreasonable requests
from others, how to assert your rights in a non-
aggressive manner, and how to negotiate to get
what you want in your relationships with others.
Traditional psychotherapy can help you identify
and change the psychological factors that inhibit
self-esteem and assertive communication. The
assertiveness training uses behavioural
techniques to teach you how to manage
interpersonal situations better. Assertiveness
requires a change in attitude as well as a change
in behaviour. We interact with others based on a
set of beliefs about status (who is better or more
important), about how we should behave in social
situations, and about what consequences we
expect from our behaviour. Non-assertive people
worry about making a bad impression on
everyone (including those who treat them badly).
They also worry about looking foolish in front of
others, and are fearful of negative consequences
all of the time.
Making a good impression, avoiding public
embarrassment, and protecting yourself are all
important traits, but non-assertive people take
them too far. They always give in to others.
Assertiveness training helps you learn how to
judge when it is reasonable and appropriate to
stand your ground, rather than giving in to
others. It is not about being pushy or aggressive