Pages 254-255 from the Management of Mental Disorders, 3rd edition, published by World Health Organization, Sydney. Editions in Australia, Canada, China, Italy, New Zealand and the United Kingdom.

Anxiety and Somatoform Disorders

Individuals with anxiety who have developed phobic avoidance as part of their disorder should be encouraged to gradually confront the things that they fear. One good way to break the avoidance is to start with confronting easy situa

tions and slowly build up enough confidence to face the harder things. This technique is called graded exposure. In doing this it is critical that they remain in the feared situation until there is a decrease in anxiety. The other important strategy for overcoming fears is to control the level of anxiety by using breathing and relaxation exercises. Regular frequent exposure will convince sufferers that they can limit their initial anxiety and confidently expect the anxiety to decrease over time.

In difficult or persistent cases, referral to a specialist who has training in the behavioural principles of graded exposure (e.g., a clinical psychologist) is recommended.

Principles Of Graded Exposure
If the phobic avoidance is mild the following principles may be applied:

1. Provide training for the slow breathing exercise (Section 4.1.2) and relaxation (Section 4.1.3). These exercises can be used prior to commencing each step of the graded exposure hierarchy to ensure that the individual is calm and relatively relaxed at the beginning of each graded exposure session. Slow breathing can be practised while in the feared situation, and targeted muscle relaxation can also be used if the individual notices tension in particular muscles (e.g., stomach muscles).
   
   
2. Help the individual Identify any exaggerated fears that occur in the avoided situations (e.g., "I will faint with fear") and decide what is more likely to happen (e.g., "I am anxious but I am unlikely to faint").
   
   
3. Remind the individual that just as anxiety initially rises when confronting at situation, it also falls within a few minutes. Only by remaining in the situation will they learn there is nothing to fear.
   
   
4. Plan a series of steps to build confidence in feared situations:
   • · Identify a first small step towards overcoming the feared situation
   • · Practise this step until it no longer causes anxiety
   • · Move on to a more difficult step and repeat the practice
   • · Continue this process until the person can manage the feared situation
     
     
5. Do not use alcohol or drugs to cope with feared situations.
   
   
6. If fears continue after the above methods have been tried, seek consultation from someone who has specialised training in the behavioural principles of graded exposure.

Problems encountered
Consider the following questions if problems are encountered during graded exposure therapy.

Is the individual trying to progress too quickly or too slowly?
Tasks that are too easy are not rewarding and tasks that are too difficult are scary and possibly demoralising. The secret to success is regular and gradual progress.

Do new steps need to be practised more frequently and for longer periods of time before moving on to more difficult steps?
It is important that the individual masters the present step before moving on to a more difficult step. Some steps are more difficult than others hence the individual may need to progress more slowly at times. Moving on without sufficient practice can lead to loss of confidence and motivation if the individual experiences a setback at the next step.

Is the increase in difficulty between steps too great?
If so, intermediate steps may need to be added so that the increase in difficulty is more manageable.

Is the individual continuing to identify exaggerated fears and replace these fears with more realistic thoughts about more likely outcomes?
Encourage individuals to ask themselves questions such as:

• "What evidence is there that [a particular event or response] is going to happen?"

• "Realistically, what is the worst thing that can happen? What if .... does happen? Will it really be so bad? What is more likely to happen?"

Remember that setbacks DO occur
If a setback occurs it may be helpful for the individual to return to a previous step at which he or she feels more comfortable. It will also be helpful to encourage the individual to view the setback in a positive light:

e.g., "I'm disappointed that I didn't do very well on this step but I have made a lot of progress so far. Setbacks are inevitable and I can learn from them. There's no hurry so I'll just take my time and start again. I'll get there bit by bit."

Edited by Gavin Andrews MD, UNSW, 2007
©2007 CRUfAD