anxiety symptoms & disorder

The patient must understand that the fight against anxiety, feelings and thoughts with leading partners for their tremendous effort, is setting the direction of his life, rather than their aspirations, goals and values ​​that would lead you to be happier. When the patient is placed in a position to fight for their values, despite its problems, has accepted the philosophy of the basic technique of desensitization, which is to confront feared situations without giving avoidance behaviors. However, the acceptance and commitment therapy provides additional techniques to ensure that the patient has understood the philosophy of exposure and cooperating voluntarily and fully in it.

We know that when exposure to the feared stimulus without giving answers avoidance or escape becomes a process of habituation occurs and, with time and perseverance, anxiety is tolerable and decreases and eventually disappears. However, Acceptance and Commitment Therapy warns that this process input raise the patient can take to consider it as the little trick I was looking to solve the problem instead of a profound change in his philosophy to face life. So you have to make it clear that there is a method to control anxiety, but a way of enhancing a phenomenon that occurs as a result of physiological law: habituation, and it works without our voluntary intervention.

When Van Riper proposed Therapy for anxiety, the technique of coping with anxiety that had shown more positive way its effectiveness is called systematic desensitization and she took her stage name described here. However, in the process of advancing cognitive behavioral therapy have been clarifying the elements that made this technique would work and demonstrated that the key is exposure to feared stimuli. Therefore it is currently used and unless the word desensitization more exposure. In this paper we have used both terms interchangeably and generally as equivalent, because the description of the phase and the techniques that made Van Riper currently have full force and has preferred to retain the term he used.

According Marks (1991) there is a highway for managing anxiety is exposure (desensitization) to the feared situation and other roads such as relaxation, muscle tension in some cases, breathing, etc. Therefore, the main objective at this stage is that the stutterer perform a therapeutic exposure to the behaviors identified in the previous phase are implicit in how stuttering, because although born to avoid stuttering, as they do not succeed have become themselves a source of anxiety. Of course we also have to expose yourself to stutter in situations you fear. Not that stutter on purpose, but it safe to happen without doing anything about it.

The process of exposure or desensitization is that the person is exposed to the feared stimulus without giving avoidance behavior, flight or fight. When it does so systematically, habituation occurs, along with the extinction of avoidance behavior, then decreases anxiety and situations are faced with increasing tranquility.

There are many examples in everyday life that give us an idea of ​​how this process. One, because it is very common, is when someone learns to swim is afraid of water. You can study many manuals, studying many styles, but if it will not ultimately exposing the water, getting wet and getting into the pool, gradually going where he covers and fears over being able to drown, he will get nothing. At first, when you advance what will happen bad, but finally, with time and perseverance, you get to enjoy bathing. There is another method to lose the fear to swim and dive into the pool directly where it covers, thus quickly gets no fear, but as long as is done with some knowledge of swimming and lifeguard is on duty to give sufficient guarantees that not going to happen.

Although there are different views on the mechanism that works in the process of exposure or desensitization, the most accepted theory is that a phenomenon of habituation by which we used to stop feeling anxiety and feelings associated with it occurs, by failing to avoidance responses. Another view is that the excitement is on the basis of anxiety disappears because it loses its functionality to not fight or flee. Yet another view is based on the extinction of anxiety and conduct preparatory actions to avoid, not make them. Yet another view is that desensitization and exposure are based on habit reversal, which is to make a new answer appears instead of anxiety in the feared situations. Actually all visions are complementary and give a full account of the process followed.

A metaphor from Acceptance and Commitment Therapy anxiety compared with a monster that lives and feeds on adrenaline. When something tells us that there is a danger, like entering a steep staircase more than expected, we perform an automatic adrenaline rush and the monster he was asleep wakes up and gets automatically us to hold on to the railing and helps us not to fall. We realize that we have the monster inside and has been, because as digests the adrenaline is strong and that he still has food to live. As time passes we see a new danger the body returns to its normal level of adrenaline and the monster hibernates, because it has enough food. When the monster itself that scares us and we want to take the body and fight to remove immediately, we again make another adrenaline rush to make the effort to combat it. The monster, happy because it has more food, grows and becomes more threatening, tells us that he will eat the brain, which is going to damage the heart and the throat is going to paralyze us forever. If we accept the monster in our body and do nothing for him to go, we will not give food and the monster will die of starvation. Always live the risk of him not to go, because we are not doing anything to get it. We'll have to get used to hear him say "what if I do not go and give you a heart attack or go crazy, or you will be blocked throat forever?" and we must not do anything that implicitly says, "Fight !, flee!" despite the fear we feel. In the stuttering glimpse a difficult word or a feeling that is not going to be able to talk, shoot and fight adrenaline begins to avoid or leave the lock. When it came out, arousal itself warns that it is in a dangerous situation and says to continue the struggle. Learning to do so is the goal of desensitization stuttering.

As in any process of habituation is imperative that events span long to give. We all know that men are able to get used to the conditions of life more difficult, but we need time and want to, that is, without exposing them to flee.

In CBT various ways to distinguish exposure.

Exhibition in the imagination, ie, imagining situations that produce anxiety and keeping in mind steadily until a change in sensation. This type of exposure is often gradually, starting with those little anxiety-producing situations, and images to relaxation meet. When done so that it is possible to imagine the situation while being relaxed and images and thoughts to feelings of relaxation, rather than anxiety associated; is called systematic desensitization. It is the first method that is empirically demonstrated that it was effective with fears already in the sixties of the twentieth century. But as Van Riper says, is not very effective to desensitize stutterers his speech because it is very difficult to imagine in detail the motor behaviors associated with their stuttering since have tried to ignore all his life. However it is indicated in many other situations.

Systematic desensitization has the advantage that is not painful. Another advantage of the exhibits in the imagination is that you can control the duration of how to do long enough so that extinction occurs.

In vivo exposure means exposure and habituation are made in the actual situation itself. A problem presented by in vivo exposure is that, in general, can not control the duration of the situation nor the constancy of stimulus necessary for habituation with relative speed is given. Therefore it is important at this stage exercises in individual sessions and group therapy in which you can prolong the situation and make the listener persists in conduct which has to accustom the stutterer until you get the habituation.

Usually tries to exposure gradually, ie they are facing situations in order of difficulty, starting with the easiest. In this case the process is called desensitization. It will then increase the difficulty to reach situations that produce higher levels of anxiety. For the same reason it has been argued for in vivo exposure, graduation is possible in practice or in group therapy sessions, but in reality situations occur randomly and can appear suddenly very difficult situations which is not yet prepared; but necessarily must be faced. In that case it should be clear that even if you avoid or get out of the situation as possible, not be interpreted as a failure or a setback, it is necessary to consider that such situations may face in the future. It is often necessary to directly attack situations highest anxiety directly, without starting with easier ones.

When exposure is performed on the most feared stimulus and the initial appearance of strong feelings of anxiety power is employing a mode of exposure is known as flooding.

Using these techniques efficiently and quickly involves technical training and very demanding for the therapist staff and need a lot of confidence in them because the patient faces considerable suffering.

As it is very difficult for their own stuttering and stammering responses provided imagine, exposures to their speech will have to live, ie acting.

Among the situations that have to desensitize are fears of words, certain sounds, certain listeners, certain communication conditions, such as time pressure, some performances listeners as not to look or nervous, or end the phrases, etc. for example, start Word by p, the sound of the phone can be stimuli that trigger their anxiety.

The phone is a generally problematic element. The characteristics of this medium impede the use stutterers, if silences give the listener can interrupt or hang up without knowing the other is blocked speechless. The stutterer does not see the reaction of the listener and is therefore more inclined to project their fears to reactions of the caller and the fear of being rejected increases. Moreover, communication is based solely on the verbal channel and can not be used gestures, etc. that help in communication. Examples of exposure must be taken into account that gives good and surprising results call strangers thousands of times, exposing them to crash.

Exposure in imagination to the worst fears that stutterers have the reactions and thoughts of the listeners is a technique that has a significant effect in reducing anxiety. Caller Rejection is often only in their thinking because when adolescence happens is rarer direct questioning or other exaggerated laughter. It is the stutterer himself who interprets different signs as signs of rejection worst you can do.Therefore exposure image of signs he sees with the thought that it is really rejected, has very positive effects in reducing anxiety stuttering.

As poses Therapy Acceptance and Commitment is not just about making a passive exhibition, become paralyzed, also seeks to expand our repertoire of responses, that is, dare to lead us as we believe it is more appropriate for the situation. In stuttering, common to many other problems condition occurs, you must do something because it is clear that, if not, will not rule, hence the proposal Van Riper go changing the way stutter to advance a way involving much less effort and, therefore, will be improved and simpler than today.

In the process of desensitization is that anxiety decreases, and check and feel the decline. Therefore it is important to start teaching the stutterer to distinguish their anxiety level, recognizing negative emotionality which has at all times, to perform exposure gradually and keep the situation long enough until the anxiety goes down and giving the habituation. Speech is as good as any of the patient's feelings barometer. Some have referred to the "no-ah" ratio tone, intensity and quality variations shown by the stutterer in his moments of fluidity as indices of their anxiety level.

Stutterers say that, throughout his life, had no choice but to confront feared situations. They do it every day and has not served them all.But the therapeutic exposure is more, as is indeed go to the dreaded, but also cease to provide the answers avoidance, postponement, etc. This is not only search for and go to feared situations, but do it in a different way, by going for the message as though it goes stopped at a blockade. When therapy is not done it will be a feared situation with the intent to run, not to mention, if it is not strictly necessary, go completely unnoticed, to end sooner, etc. When therapy is done it goes with intention to speak, they note that stutters, to say everything you need, even stuttering, no run, etc. In therapeutic exhibition seeks risk controlled manner.

Indeed, the confrontation as it has been doing the stutterer so far gives no results. He's been in situations in which he has been afraid to speak a thousand times, but always trying not to stutter and leave them as quickly as possible. For it has been conducting all avoidance behaviors, delay, start, etc. in their desperate to control their speech and anxiety attempts and has maneuvered the situation shortest time possible. In the modification of these issues lies the change becomes therapeutic exposure. To make the exposure therapy has to stop doing those answers and have to face the situation without trying to escape it, assuming all risk having blocked, and go not daring to use crutches or change words, to finish phrases, etc. etc.

Given this approach is clearly the advantage that make exposure in stages, so that will be taking the experience of the results obtained when the risk is assumed.

The most revolutionary experience of managing anxiety is when, first query, do not do any extra effort to own speech to exit the lock and check that the release occurs by itself, the sense of flow for which both have fought one finally arrives when the fighting is allowed. This requires daring to do absolutely anything extra when you are in blocking and of course take all the time necessary for it to occur. As a metaphor that explains this fact serves to show when we move while wearing a seat belt of a car. If we make the effort just the right speed, we can move freely, but if we go fast belt locks and we were locked. To exit the lock must stop straining and exercise only the right to move without running. If we do more to get proper force, pulling forward the belt still hold us more forcefully.

A metaphor that explains the meaning of the exhibition is to befriend anxiety. To befriend a person must cultivate his friendship, ie dedicate time to know, not reject it, let it come to us and is displayed as it is, with all its capabilities, so we must let freedom make their wishes and it roam their respects, which can fully display as is, without putting hindrance in his action, he wants us to know, it's really capable of making and leave it to do. As important knowledge of the friends element is to know what they say they do and distinguish it from what they actually do, there are those who are a little bluffers and fulfill what that "from words to action is a long way". Anxiety is catastrophic, but their black predictions are not always met.

Anxiety as any human response can be viewed from different angles that are considered classically in psychology, cognitive, behavioral and emotional. We must clarify that it is not independent components but different views of the same phenomenon. So if you start studying cognition, ie, thoughts, will be associated to emotions and feelings and that both thoughts and emotions, have the mission to promote emission behavior. If the process is observed from the behavior is that you have to give emotional and cognitive to carry it out preparation and if done from the emotional point of view is found that emotions are prepared to act (Frijda, 1986) involving associated thoughts and sensations.

The cognitive component of anxiety in stuttering what are the thoughts of the disaster is approaching and the need to do anything to avoid it.

The quality of these thoughts is that they are neither explicit nor sharp nor complete. This lack of clarity is due in part to the automation process we employ human when we think. Because when we had thought many times, each time we summarize more and more content, to go saving time and energy. In this process we leave it in a sentence, a sound or an image that produce the same effect as full thought and fulfills its function to prepare to act; finally can be automated completely and we realize that what we thought, except for the feeling appears to us without our conscious of any thought.

To disable automatic thoughts, we must first identify them. Normally just look at the chunky feel and ask that wants to tell us, the answer is still the original thought. To make this process you can follow the directions of Bandler and Grinder (1980) attempting concrete, eliminating ambiguous words (something it, etc.), universal quantifiers (always, everything, never, etc.), construction of unclear phrases or incomplete ...

When you have obtained the complete thought can make a first content analysis to see if it makes sense or not and whether or not responding to the current reality. Beck (1975) was the discoverer of the importance of automatic thoughts and created cognitive therapy, which is based on logical analysis of automatic thoughts. Beck, an analysis of their content, based on the view that the pathology develops due to illogical or wrong thoughts and simply exchange them for real and logical to give improved.

In clinical practice are cases where the automatic thought is illogical and can be changed by going only to the analysis of their content, are automated schemes are held exclusively by its characteristic of being unconscious and just make them explicit to be disabled; but unfortunately not all we want to change automatic thoughts are illogical and even if it were, we are often aware that not make sense, but not disappear.

The Acceptance and Commitment Therapy considers the thoughts and behaviors associated with our daily behavior and rightly points out that they are also subject to the laws of conditioning. So irrational thoughts can stand on its contingencies of reinforcement, ie, because we are used to prevent or are reinforced by our conduct, and maintained for it and not only for its internal logic.

Hayes et al (1999) also point to another phenomenon which maintains and enforces thoughts that are harmful to the person and is the belief in the literal language. Take language literally means the difference between the content of thought and reality reflecting, ie, when we react to thought like a real event that has occurred is not distinguished. In individual cases it is easy to distinguish, if we speak of a chair, for it is well described, we can not sit on it. The rejection that often feels the stutterer in communication is a good example of how the literal language works. In a conversation there may be a thought that speaking as of today will not be able to keep the conversation and the other is going to get bored and feel it when observed jams and struggle to speak. If acts as if it were true, ie, believing that you can not continue the communication and the other is getting bored and feeling sorry, it's likely that the conversation as quickly as possible is abandoned, and actually makes the thought that until then was just a set of words, because the end of the message due to stuttering occurs.

To disable the literal language there are two parts in emotional thinking. One part is a catastrophic prediction of the future that awaits us, that usually gives us much fear, in the example, is that the other will get bored or feel sorry. This part can be reasonable and probable, but not a fact and no one says the other is feeling bad. The second part of the thinking tells us how we should behave to avoid suffering to the true fact of rejection, in the example, cut the conversation and leave. When we follow these directions is when we believe in the literal and when they become reality.

So the thought that will cause a jam itself generates anxiety, although it has in the solitude of the bedroom, because we react to thought as if what he says has already occurred or outside happen immediately.

In Acceptance and Commitment Therapy bus metaphor used to describe the function of thoughts:

In life we ​​are driving a bus on the road toward our goals and our values ​​engine. We took a few unruly passengers, who are our thoughts, feelings and emotions. All of them are catastrophic, "If you follow that road going to suffer a lot", "you're going to crash," "going to have an accident", "you're going to bog", "they will laugh at you." And tell us implicitly: "twists and", "do what it is to avoid it."

We have several alternatives:

The physical sensations

Emotional feelings

1. The first step is to make a place to feel, leaving aside the thoughts and rationality realizing what we feel.
2. It involves identifying the feeling is above (or below) of all physical sensations, and encompasses all evens marking us a unique feeling. It's like the feeling that goes beyond the specific physical sensations we have is more general than them, with less body location, but often sits in the center of the body, others felt in the head, and most anywhere certain place.
3. A heartfelt time, it's getting half to anchor to relate to it, can be a word, a phrase, an image, sound, etc. When we can not think we free our mind and soon she will attend that evokes the sensation. We tried and we checked, and gradually we can Irlo specifying and focusing in more detail.
4. Then allowed to resonate, ie repeat and maintain that which evokes and let it evolve until it changes the feel freely.
5. We hope to change that will inevitably occur. What will notice a change in the felt sense. It may take several minutes or longer, it is a matter of patience.
6. We identify our new felt sense and relate to her again.
7. Before resonate again, we stopped and we are aware of the changes that have occurred and mean changes we have experienced.

Some ideas about how to conduct exposure

An example of exposure in imagination

Paradoxical intention as flood