First Phase

The first phase of treatment is characterized by refraining from use of cognitive techniques, which are deferred to a later stage, and extensive use of behavioral strategies. Patients are asked to make a list of situations, rated on a 0- to 100-point scale, that cause distress and/or induce avoidance. Anxiety is regarded as much a target for treatment as is depression. Exposure therapy (assignment of homework activities in a structured diary) is implemented when avoidance is identified (e.g., phobia disturbances). In vivo situational exposure exercises should be specific for each day and well defined in terms of duration, situation, and what the patient must do or not do.

It is important that patients understand that exposure must induce discomfort: Patients should be informed that the increase of anxiety during exposure exercises is a sign that what they are doing is working.

In general, patients' disturbances are conceptualized in terms of inhibited central pleasure-reward mechanisms (e.g., low self-esteem, pessimism), central pain disturbances (e.g., sadness, anxiety, excessive regard for potentially adverse consequences of action), and psychomotor regulation (e.g., exhaustion, slowing of thoughts), according to the model advanced by Carroll (1991). This first phase of treatment is mainly involved with behavioral techniques for inhibited psychomotor regulation and anxiety in central pain disturbances.

We feel that treatment of anxiety is often insufficiently emphasized during CT for depression, probably since anxiety is regarded as a by-product of depression. However, as discussed in detail elsewhere (Fava, 1999), at least in certain types of depression, anxiety and irritability are prominent in the prodromal phase of depression, may be concealed by mood disturbances in the acute phase, and are again a prominent feature of the residual phase. Behavioral techniques are implemented also to increase general activities by writing simple tasks in a diary, which may counteract loss of activities related to fatigue and anhedonia.

This initial phase extends over four to six sessions. During this part of treatment, the antidepressant drug that the patient was taking on intake is kept at the same dosage. Attitudes of the patient toward pharmacotherapy are explored. Often patients conceive treatment of depression in purely pharmacological (external) terms and need to be educated about the importance of self-therapy. An example we frequently use has to do with lowering cholesterol levels. Drugs may be important, but they achieve insufficient results if the patient does not attempt in his/her diet to lower the intake of food high in saturated fats. Other patients perceive their lack of response to drug treatment as personal failure and confirmation of their inadequacies. We tell these patients that because drugs are effective only for two out of three patients, and no drug is effective for everybody, other strategies frequently need to be involved.

Getting to Know Anxiety

Getting to Know Anxiety

Stop Letting Anxiety Rule Your Life And Take Back The Control You Desire Right Now! You don't have to keep letting your anxiety disorder run your life. You can take back your inner power and change your life for the better starting today! In order to have control of a thing, you first must understand it. And that is what this handy little guide will help you do. Understand this illness for what it is. And, what it isn't.

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