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Barlow defines anxiety as a negative mood state that is lead by physical symptoms such as increased heart rate, tightness of the chest, feeling tense, panic attacks and increased breathing (2002). Most individuals experience some level of anxiety at one point in their lives however those who feel overwhelmed and constantly distracted by the anxiety symptoms where it starts to interfere with their everyday life in a significant way develops a anxiety disorder. Anxiety disorders emerge from biological and psychological vulnerabilities that increase the risk of developing a disorder (Suárez, Bennett, Goldstein & Barlow, 2009). This review will critically examine a set of journal articles about how to work with anxious clients in crisis. Additionally different crisis intervention techniques will be explored for anxiety such as Cognitive behavioural therapy (CBT), Acceptance and Commitment therapy (ACT), Mindfulness based therapy (MBT) and Eye movement desensitization and reprocessing (EMDR). This review will also discuss how best to assess and identify anxious clients using assessment tools such as Beck Anxiety Inventory (BAI), Penn state worry questionnaire (PSWQ) and the GAD-7.
Anxiety can be a positive symptom in certain situations. It can serve a purpose by motivating an individual and encouraging them to be more creative or step out of their comfort zone which can help a person grow (Antony & Barlow, 2002). However, when individuals have an anxiety disorder they worry all the time which can be exhausting and start to hinder and limit all aspects of their everyday life (Kangas, 2014). Cognitive behavioural therapy has a strong evidence base for treating the various forms of anxiety, such as Generalised anxiety disorder (GAD), Social anxiety disorder (SAD), Obsessive- compulsive disorder (OCD) and Panic disorder. Generalised anxiety disorder is characterised by prolonged periods of uncontrollable anxiety about everyday events associated with a variety of physiological reactions. Leahy, Holland and McGinn (2011) define social anxiety disorder as excessive fear of one or more social situations. Situations that commonly initiate anxiety include giving speeches, attending social gatherings, disagreeing with others, talking to authority figures and any public performances. A study by Grant, Hasin, Blanco, Stinson, Chou and Goldstein (2005) found that the average number of situations feared by people with SAD was seven, with over 93% reporting three or more fears. Kangas (2014) describe panic disorder as a sudden, intense anxiety accompanied by constant panic attacks that involve intense fear which are fuelled by misattributions of physiological symptoms. Obessive-compulsive disorder is one of the most debilitating of all anxiety disorders because if left untreated it can destroy a persons ability to function (Leahy, Holland & McGinn, 2011). OCD is characterised by repeated thoughts, urges or images that create an obsession. When these thoughts become recurring it can influence unhealthy patterns of behaviour which causes difficulty in daily functioning (Leahy, Holland & McGinn, 2011). A study by Diefenbach, Abramowitz, Norberg and Tolin (2007) researched changes in quality of life (QOL) following CBT for obsessive-compulsive disorder. Functional impairment aspects of QOL measured by the Sheeran Disability Scale were assessed among 70 adults with OCD before and after CBT. Results suggested significant improvements in QOL, social and family functioning and improvements in OCD symptom severity (Diefenbach, Abramowitz, Norberg, Tolin, 2007).
Cognitive behavioural therapies (CBT’s) are the most well established psychosocial treatments for anxiety disorders and are usually recommended by healthcare professionals as the initial treatment for individuals experiencing anxiety (Tolin, 2010). CBT is a evidence based short term psychological treatment that recognises the way we think (cognition) and act (behaviour) affects the way we feel. CBT provides an individual a opportunity to recognise unhelpful patterns that are contributing to their anxiety and provide coping skills to approach situations more rationally (“Beyond Blue”, 2019).
CBT uses a multimodal approach and targets the three main symptomatic responses, cognitive, behavioural and physiological. Common CBT components in anxiety disorder interventions are; pychoeducation, relaxation training techniques, cognitive restructuring, exposure techniques, problem solving and social skill techniques (Kangas, 2014).
Whilst CBT has a long standing history of evidence based and successful research outcomes, there is emerging treatments that have equally had success. Examples of this include Mindfulness based therapies, Acceptance and commitment therapy (ACT) and Eye movement desensitisation and reprocessing ( EMDR). In contrast to CBT treatment, mindfulness based therapies (MBT’s) seek to change the relationship between the anxious person and their thoughts. In MBT the client focuses on the physical sensations that arise when the anxious. Instead of avoiding or withdrawing from these feelings clients stay present in the moment and fully experience the symptoms of anxiety (Hofmann, Sawyer, Witt & Oh, 2010). The purpose to remain present in the symptom is merely a reaction to a perceived threat. By focusing on mindfulness to help respond to a threat in a positive way instead of reacting to it, clients can overcome a fight or flight response (Hofmann, Sawyer, Witt & Oh, 2010). At the University of Bergen in Norway, Vollestad, Nielsen, and Nielsen surveyed 19 studies of the effectiveness of MBTs on anxiety. They found that MBTs are associated with robust and substantial reductions of anxiety symptoms. MBTs proved as effective as CBT, and are generally less expensive (Vollestad, Nielsen & Nielsen, 2011).
Acceptance and commitment therapy is a acceptance based behavioural therapy that is successfully used to treat anxiety disorders. ACT prioritises mindfulness, acceptance and cognitive defusion which aims to decrease internal discomfort and help change the clients behaviour to more in line with their personal values (Hayes, Strosahl & Wilson, 2002). A study by Twohig, Hayes, Plumb, Pruitt, Collins, Hazlett-stevens and Woidneck,(2010) investigated the effectiveness of 8 sessions of ACT for adults diagnosed with OCD compared with progressive relaxation training (RPT). Authors completed a pre treatment, post treatment and 3 month follow up by an assessor who was unaware of treatment conditions. Results indicated ACT produced greater changes at post treatment and follow up over RPT on OCD severity. Clinically significant change in OCD severity and marginally in favour of improved quality of life (Twohig et al, 2010).
Another successful emerging therapy used to treatment anxiety is eye movement desensitisation and reprocessing (EMDR) which was developed by Francine Shapiro in 1987. EMDR is used to alleviate anxiety symptoms by the therapist directing eye movement while the client imagines distressing scenarios and the therapist helps shift their attention towards more positive thoughts, causing anxiety to dissipate.
In order to ensure the clients anxiety is appropriately managed the clinician would approach assessment utilising the following evidence based assessment, along with a semi structured clinical interview. The Beck Anxiety Inventory (BAI) was developed to help differentiate between behavioural, emotional and physiological symptoms in individuals with anxiety and depression (Beck & Steer, 1990). The BAI is a 21 question multiple-choice self report inventory used to measure anxiety symptoms experienced in the past week. Each answer is scored on a scale value of 0 (not at all) to 3 (severely). The higher the score the more severe the symptoms are. A study by Osman, Hoffman, Barrios, Kopper, Breitenstein and Hahn examined the validity and reliability of the BAI in samples of adolescents ranging form 14 years and 18 years. Results showed acceptable psychometric properties in this age group (Osman et al, 2002). The BAI has been criticised for its strong focus on the physical symptoms of anxiety such as numbness, tingling and sweating. Therefore therapists often pair the BAI with the Penn state worry questionnaire which provides a more accurate assessment of the cognitive symptoms of anxiety.
Penn state worry questionnaire (PSWQ) is one of the most widely used assessment tools to measure the intensity and frequency of worry which was developed by Meyer, Miller, Metzger and Borkovec in 1990. PSWQ is designed to assess the generality, excessiveness and the realm of pathological worry (Meyer, Miller, Metzger & Borkovec, 1990). PSWQ consist of 16 items which are scored from 1 (not at all like me) to 5 (very topical of me) (Meyer, Miller, Metzger & Borkovec, 1990). Due to the increasing need for assessments to be available online for clients, authors Verkuil and Brosschot (2012) conducted a study to explore the psychometric aspects of the penn state worry questionnaire as administered via the internet. The study focused on examining the factor structure , predictive validity and reliability of the questionnaire administered via the internet (Verkuil & Brosschot, 2012). Results indicted evidence to suggest the online version of the PSWQ possesses psychometric properties that are similar to the paper and pencil version. The results are encouraging because it will allow clients the flexibility and also the opportunity to participant in the questionnaire even if you are remote.
Another questionnaire that is normally correlated with the PSWQ is the generalised anxiety disorder seven item questionnaire (GAD-7). The GAD-7 is a seven item self report questionnaire developed by Spitzer, Kroenke, William and Lowe (2006) designed to assess the clients anxiety status during the previous two weeks. The seven items ask the client the degree of agitation of feelings, for example, feeling nervous, anxious or on edge, having trouble relaxing, excessive worry, can’t sit still and becoming easily annoyed (Spitzer, Kroenke, William & Lowe, 2006). When comparing the GAD-7 with the PSWQ the GAD-7 was found to be more sensitive in detecting change in the status within a clinical setting. However both questionnaires have internal validity (Williams, 2014).
In conclusion, to effectively work with anxious clients who are in crisis the following assessments were explored and reviewed. Questionnaires such as beck anxiety inventory, penn state worry questionnaire and the GAD-7 can all be used to assess, measure and differentiate anxious symptoms such as behavioural, emotional and physiological. Once the client is assessed, intervention techniques are used to decrease the clients symptomatic responses. There is significant evidence for the efficacy and effectiveness of utilising CBT as treatment for anxiety. Whilst CBT has a long standing evidence base research, emerging successful treatments emerged, which was explored in this review. For example, Mindfulness based therapies, Acceptance and commitment therapy and Eye movement desensitisation and reprocessing. These interventions are commonly used to support a client presenting with anxiety or is experiencing severe anxiety symptoms and an important part of crisis intervention to support and stabilise anxious clients.
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- Suárez, L, Bennett, S., Goldstein, C., & Barlow, D.H. (2009). Understanding anxiety disorders from a “triple vulnerabilities” framework. In M.M. Antony & M.B. Stein (Eds.), Oxford Handbook of anxiety and related disorders (pp. 153-172). New York, NY: Oxford University Press.
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- Twohig, M., Hayes, S., Plumb, J., Pruitt, L., Collins, A., Hazlett-Stevens, H., & Woidneck, M. (2010). A Randomized Clinical Trial of Acceptance and Commitment Therapy Versus Progressive Relaxation Training for Obsessive-Compulsive Disorder. Journal of Consulting and Clinical Psychology, 78(5), 705-716.
- Verkuil, & Brosschot. (2012). The online version of the Dutch Penn State Worry Questionnaire: Factor structure, predictive validity and reliability. Journal of Anxiety Disorders, 26(8), 844-848.
- Vollestad, Nielsen, and Nielsen (2011). Mindfulness and acceptance-based interventions for anxiety disorders: A systematic review and meta-analysis
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