Vicious Cycle Presenting Problem Psycho education Worksheets updated version

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Alex’s physical symptoms Panic attacks Heart palpitations Chest pains Sweating Dry mouth Feelings of choking Hot

Alex’s behaviours Only going out with someone Avoiding busy, crowded places and times Avoiding exercise and sex Leaving places quickly Shopping online Taking water everywhere

©The CBT Resource® 2016-2021

Alex’s altered thoughts “I am having a heart attack” “All this anxiety is bad for my heart” “If I go anywhere I won’t be able to get help” “I must avoid bringing on another attack”

Alex had panic disorder with agoraphobia He experienced rapid rises in his anxiety levels, which built to a peak within minutes. He thought he was having a heart attack at the time. This could be triggered by his physical symptoms, places or even the thought of going out of his flat. Sometimes it seemed to come out of the blue when he felt calm too.

He tried avoiding things that brought on his anxiety and also doing things to make it go away more quickly when it did. In the short term, this gave him some initial relief, but in the longer term it maintained his panic and anxiety and kept him in a vicious cycle of avoidance. He found it increasingly difficult to go out without having someone with him. He used an evidence-based CBT approach called exposure and habituation to successfully address his difficulties.

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Ruth’s physical symptoms

Shaking Sweating Blushing Heart palpitations Dry mouth Hot Panic attacks

Ruth had social anxiety disorder

Ruth felt very anxious and uncomfortable in social situations.

She would dread any upcoming event where she had to speak to new people and thought they would judge her negatively.

This became particularly difficult when she started university to train as a nurse. She had to meet new people, go on placement and give presentations to her peers as part of her assessments and found this too anxiety provoking to do and experienced intense anxiety as a result. Afterwards she would go over and over them in her mind. She would try and manage her anxiety by avoiding social situations. This gave her some initial relief in the short term, but in the longer term it maintained her anxiety. She used an evidence based approach called Cognitive Behavioural Therapy (CBT) to successfully help with her difficulties. ©The CBT Resource® 2016-2021

Ruth’s behaviours Avoiding social situations Wearing extra concealer to avoid looking red in the face Using lots of deodorant and wearing dark clothes to disguise sweating Avoiding eye contact Not making friends at university Rushing through presentations Taking herbal calm tablets

Ruth’s altered thoughts “People will find me boring” ‘People will notice me sweating and think I’m disgusting” “If others see how anxious I am they will think badly of me it would be so humiliating “I won’t be able to speak”

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Mark’s physical symptoms

Difficulty getting to and remaining asleep Muscle tension and irritability Fatigue Poor concentration Headaches

Mark’s behaviours

Drinking lots of coffee Napping in the daytime and weekends Missing or being late for work Using alcohol at night to try and sleep

©The CBT Resource® 2016-2021

Mark’s altered thoughts “What if I don’t sleep tonight” ‘If I don’t sleep I wont be able to do anything tomorrow” “If I am late for work again my boss will sack me”

Mark had insomnia Mark had experienced sleep problems for several months. He did not wake up feeling refreshed and wanted to be able to sleep better. He worried about not being able to sleep and the consequences for him the next day at work and home. The more he worried about not sleeping, the worse he slept. He felt tired in the day time and it affected his concentration at work.

He would drink lots of coffee to try and make it through the day. He was finding it difficult to get work done on time and would often nap on the sofa at try to catch up at weekends. He also noticed he was becoming more irritable with his partner and young daughter. Mark was in a vicious cycle. He used an evidence based approach called Cognitive Behavioural Therapy (CBT) to overcome his insomnia.

Binita’s physical symptoms

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Tension Blurred vision Sweating Panic attacks

Binita’s altered thoughts “What if the Dr has missed something” ‘A headache means I do have a brain tumour and will die” “If I have got a brain tumour my family won’t will be left alone” “I must prevent headaches”

Binita’s behaviours Checking for any changes in her vision or other body symptoms Avoiding bright lights Wearing dark glasses to avoid getting a headache Avoiding bright lights Going to her GP regularly and asking for help and tests Taking paracetamol to prevent a headache coming on

Binita had illness anxiety disorder (sometimes called health anxiety) Binita worried that she could have a brain tumour. She had been given a number of tests by her GP and other healthcare professionals over the years and everything had come back clear. This would reassure her for a short while, but it didn’t last for long and her worries would come back that they could have missed something. Worrying about her health and checking for signs of being ill took up a significant part of her day and made her feel very anxious. She would pay attention to her body and notice any changes that happened, for example if she got a headache. This would confirm to her that something had been missed. She used an evidence based approach called Cognitive Behavioural Therapy (CBT) to help with her difficulties. ©The CBT Resource® 2016-2021

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Liz had Obsessive Compulsive Disorder (OCD)

Liz’s physical symptoms

Heart racing Sweating Nausea Panic attacks

Liz’s behaviours Replacing the distressing images with an image of him safe Avoiding picking him up unless someone else was around Avoiding being alone with him Locking away knives in the kitchen Not holding him over hard floors or objects

©The CBT Resource® 2016-2021

Liz’s altered thoughts Distressing images of Liam injured because she dropped or stabbed him “I shouldn’t have these thoughts” “Thinking these bad things is as bad as doing it” ‘What if something happens to him and I am responsible”

She had recurrent, unwanted intrusive images of harming her young baby Liam (obsessional thoughts). Understandably, they made her feel highly distressed and anxious, as this was the last thing she would ever want to do. She would carry out a range of things (compulsive behaviours) to try to manage her distress and avoid any harm coming to him that she could be responsible for. In the short term, this gave her some relief from her distress; but in the longer term it maintained her difficulties keeping her in a vicious cycle of obsessional thoughts and compulsive activities. She used an evidencebased CBT approach called exposure and response prevention to successfully help with this.

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Antony’s physical symptoms

Tiredness Nausea Tension Not sleeping well Concentration difficulties Appetite reduced

Antony had depression with anxiety Antony was a retired antiques dealer and lived with his wife Jane, who had been diagnosed with dementia last year. He had always had a tendency to worry. Antony loved his wife dearly, but caring for her at home became difficult. Jane could be challenging physically. She didn’t sleep well which meant he didn’t either. She often forgot who he was, which he found devastating. Antony didn’t want Jane to go into a home or have carers come into the house. He felt he should be able to manage by himself.

His own mood became lower and he felt anxious much of the time. He used an evidence-based CBT approach called Behavioural Activation to successfully help him to manage his mood.

©The CBT Resource® 2016-2021

Antony’s behaviours

Avoiding seeing his friends or doing his own hobbies Worrying about the future for Jane and his ability to cope Avoiding doing things around the house, except for looking after Jane Not eating properly or resting

Antony’s altered thoughts “I need to put Jane’s needs first” “I am losing her a bit more every day” “I feel so guilty, I am letting her down” “What if they see I can’t manage and they take her away from me”

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Nate had depression

Nate’s physical symptoms

Difficulty falling and remaining asleep.

Lacking energy and motivation Poor concentration at work Irritable

Nate’s behaviours Late for work Avoiding seeing his friends or socialising Napping in the daytime Staying in bed Not eating properly and stopped going to the gym Using alcohol to try and sleep

©The CBT Resource® 2016-2021

Nate’s altered thoughts “I can’t be bothered anymore” ‘It is all just too hard” “What is the point in doing anything, I won’t enjoy it” “I am rubbish company” “I am letting my friends down”

He had been feeling down for about six months which eventually led to him being signed off work and college. He was under threat of losing his electrician apprenticeship due to poor time keeping and not concentrating. He didn’t want people to know how he was feeling.

Nate had a range of symptoms of depression such as poor sleep and concentration. He began avoiding doing things because of how he was feeling.

Initially this gave him some relief, but in the longer term it added to his difficulties.

Nate was in a vicious circle of depression. He used an evidence based approach called Cognitive Behavioural Therapy (CBT) to manage this.

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Leah had depression

Rebecca’s physical symptoms

Lack of energy and motivation Fatigue and agitation Aches and pains Appetite and sleep problems

Rebecca’s behaviours

Stopping doing things other than caring for Adio Avoiding seeing relatives and friends Not able to engage in conversation or concentrate on a TV programme Not playing with Adio

©The CBT Resource® 2016-2021

Rebecca’s altered thoughts “Other people love being a Mum, what is wrong with me” “Adio deserves better” “I can’t be bothered” “There is no point in doing anything; I won’t enjoy it and I don’t have time now”

Leah began to feel low in mood towards the end of her pregnancy, which became worse after Adio was born. She had felt depressed for about six months.

She felt helpless and hopeless about the future and had lost all interest and pleasure in things.

She had to force herself to eat and take care of herself for Adio.

Her husband Joseph was worried about her, but even when he took care of Adio, Rebecca found it difficult to sleep and switch off. Rebecca was in a vicious circle of depression.

Her midwife picked up on her mood and suggested she was referred for therapy. She used an evidence based approach called Cognitive Behavioural Therapy (CBT) to successfully help with her difficulties.

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Lou’s physical symptoms

Heart racing initially Blood pressure then rapidly dropping Fainting

Lou’s behaviours Rescheduling knee operation Avoiding vaccinations Avoiding going to the dentist when need dental work Not watching TV shows where there could be blood, needles or accidents Avoiding situations where she or others could cut themselves

©The CBT Resource® 2016-2021

Lou’s altered thoughts “I will collapse and hurt myself” ‘If I see a needle or blood, I won’t cope” “I can’t stand it, it will harm me somehow” ’It is silly that I am like this, I know it is only blood”

Lou had a specific phobia of blood, injection and injury She experienced high levels of anxiety if she came into contact with any references, images or actual blood, injuries or injections.

She struggled to even write the word blood or look at still or moving images of needles or injections. She would try to avoid these things at all costs. This gave her some relief from the fear in the short term, but in the longer term maintained her difficulties. She needed an operation on her knee after a running injury.

She used an evidence based approach called Cognitive Behavioural Therapy (CBT) to treat her phobia.

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Eve’s physical symptoms

Heart racing Sweating Shaking Dizziness Panic attacks

Eve’s altered thoughts “I can’t stand it” ‘If I get anxious I won’t be able to cope” “If I get dizzy I will fall” “What if I fall and die”

©The CBT Resource® 2016-2021

Eve’s behaviours

Avoiding looking out of windows above ground level Not going to university lectures, shops or public places where there were cliffs, multi stories or balconies Not talking elevators or lifts Driving the long way to avoid crossing bridges

Eve had a specific phobia

She was terrified of heights. She had tried to adapt her life to avoid all situations which involved being up high where possible. She knew that her fear was excessive to the situation, but she couldn’t even stand the thought of heights. At university this meant she was struggling with being in some buildings and lecture rooms which had begun to affect her studies. She had even chosen a ground floor room in halls so she didn’t have to use the lift or look out of the window above ground level.

She used an evidence based approach called Cognitive Behavioural Therapy (CBT) to help with her difficulties.

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Sam’s physical symptoms

Heart racing Feeling hot Sweating Shaking Trembling Panic attacks Tension

Sam had Social Anxiety Disorder He specifically experienced anxiety when he had to give a speech or talk in front of other people he didn’t know well. These things would bring on such intense anxiety and distress that he avoided them wherever possible. He felt really anxious that he would do it wrong, stutter, forget his words or that people would see how anxious he was and think badly of him. His best friend Andrew was getting married in a few months time and had asked Sam to be best man. He really wanted to say yes, but was worried as he knew that he would not manage the speech without help. He used an evidence based approach called Cognitive Behavioural Therapy (CBT) to help with his difficulties. ©The CBT Resource® 2016-2021

Sam’s behaviours Avoiding situations: dropping out

of an interview for his dream job as a designer, not speaking at his Dad’s funeral.

Keeping his hands in his pocket when talking to people Avoiding eye contact Wearing strong deodorant and loose clothing

Sam’s altered thoughts “I will stutter and go wrong” ‘Everyone will stare at me” “If they see how anxious I am, they will think I am pathetic” “They will think I am stupid” “I will make a fool of myself” “What if I mess up for Andrew”

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Jamie’s physical symptoms

Heart racing Sweating Pins and needles Chest pains Palpitations Panic attacks

Jamie developed Panic Disorder after having a heart attack James had experienced a heart attack and after he recovered from this he would experience episodes of high levels of intense anxiety which built to a peak in minutes. He would have a range of distressing physical symptoms and thought at those times he was having another heart attack. He tried to avoid triggers for his symptoms, but they could come on at any time and out of the blue. He understandably wanted to avoid having another heart attack and feeling this way. He used an evidence based approach called Cognitive Behavioural Therapy (CBT) to help with his panic disorder.

©The CBT Resource® 2016-2021

Jamie’s behaviours Avoiding exercise and sex Taking the lift not the stairs Avoiding caffeine Not doing anything that brought on exertion such as walking Taking his GTN spray just in case

Jamie’s altered thoughts “I am having another heart attack” “I am going to die” “All this anxiety is damaging my weak heart further” “I must try and prevent this”

Tommy had Obsessive Compulsive Disorder (OCD) He had unwanted and persistent thoughts (obsessions) about contamination from dirt and germs that would make him responsible for making his family becoming seriously unwell. He would try to suppress the thoughts, but they kept coming back. He had to carry out intensive hand washing and cleaning rituals to reduce the distress with disinfectant and bleach until it felt ‘right’ (compulsions). His OCD took up several hours a day and his hands were raw from the scrubbing. This was affecting his work in retail as he was embarrassed to let people see his hands and because his compulsions took up so much time. The cost of cleaning products was also taking up a lot of his salary. He used an evidence based CBT approach called Exposure and Response Prevention to help with his difficulties. ©The CBT Resource® 2016-2021

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Tommy’s physical symptoms

Heart racing Sweating Palpitations Panic attacks Intense feelings of anxiety and distress

Tommy’s behaviours Trying to suppress his thoughts Excessive use of cleaning products Avoiding contact with dirt and germs Washing hands with bleach and scrubbing them until feels ‘right’ Avoiding preparing food for others

Tommy’s altered thoughts “I am contaminated, they will come to harm and I am responsible” ‘What if they get unwell because of me” “I am responsible; I must prevent it happening”

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Izzy’s physical symptoms

Heart racing Sweating Shaking Panic attacks

Izzy had specific phobia Izzy’s phobia was of flying. She managed this by avoiding going anywhere by plane for many years.

Then a change at work meant she would need to fly to the Scottish and international offices of her company on a fairly regular basis due to a new project and there wouldn’t be time for her to travel any other way.

Izzy wanted to do the project and could not avoid taking visiting the other offices much longer. She also wanted be able to go on holiday with her partner somewhere exotic for her honeymoon.

She used an evidence based approach called Cognitive Behavioural Therapy (CBT) to help with her difficulties.

©The CBT Resource® 2016-2021

Izzy’s behaviours

Avoiding flying Only going on holiday by car, train, ferry or coach Not watching TV programmes where there may be flying Calling in sick to avoid having to go on work trips

Izzy’s altered thoughts “It isn’t safe, it will crash” ‘If I get anxious, I won’t cope” “If there is turbulence we will come down” “I know logically it is ok, but I can’t stand it

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Erhan’s physical symptoms

Erhan had Generalised Anxiety Disorder

Tension Headaches Restlessness Difficulty concentrating Irritability Sleep difficulties

Erhan’s behaviours Worrying excessively Avoiding uncertain, unpredictable or uncontrollable situations Seeking reassurance from others Over preparing at work Procrastinating making decisions

©The CBT Resource® 2016-2021

He worried excessively about his work, his relationship, fiances and family. He experienced anxiety most days along with tension which led to headaches and difficulties sleeping.

Erhan’s altered thoughts “I am losing control” “All this worrying is bad for me” “What if I make a mistake and lose my job” “What if Rachel leaves me” “What if I cannot cope”

He tried avoiding situations that felt uncertain, unpredictable or uncontrollable. He brought work home in the evenings and checked his teams work for errors. In the short term, this gave him some initial relief, but in the longer term it maintained his worrying and anxiety and kept him in a vicious cycle. He found it increasingly difficult to stop worrying and make decisions.

He used an evidence-based CBT approach called Worry Management to successfully address his difficulties.

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Sam’s physical symptoms

Sam had Generalised Anxiety Disorder

Tension Headaches Restlessness Difficulty concentrating Irritability Sleep difficulties Aches and pains

She worried excessively about a range of things including her work as a teacher and her health.

She experienced anxiety and tension most days and struggled to sleep.

Sam’s behaviours

Sam’s altered thoughts

Execsive worry Difficulty stopping worrying Trying to maintain control and certainty Seeking reassurance from others Over preparing at work Procrastinating decisions

“What if lose my job” “What if I am going crazy” “What if I get it wrong” “Worrying helps me to prepare incase something bad happens” “What if I cannot stop worrying”

©The CBT Resource® 2016-2021

She struggled with making decisions and situations that felt uncertain, unpredictable or out of her control. She would put things off and seek reassurance from friends and family. In the short term, this gave her some initial relief, but in the longer term it maintained her worrying and anxiety and kept her in a vicious cycle.

She used an evidence-based CBT approach called Worry Management to successfully address her difficulties.