Cognitive Therapy of Anxiety Disorders

A Practice Manual and Conceptual Guide

Adrian Wells

• Publisher: Wiley
• Year: 2013
• ISBN:
  9781118725429
• Edition: 1
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

Cognitive therapies are based on the idea that behavior and emotions result largely from an individual's appraisal of a situation, and are therefore influenced by that individual's beliefs, assumptions and images. This book is a comprehensive guide to cognitive therapy of anxiety disorders.

Chapter 1

COGNITIVE THEORY AND MODELS OF ANXIETY: AN INTRODUCTION

There is no single cognitive theory or model of anxiety disorder. This book focuses primarily on the approach of Beck and allied approaches, which are among the most influential and are supported by data from rigorous experiment and self-report studies. Since the concept of cognition is central in this volume it is necessary to define what is meant by this term in the present context. In its broadest sense cognition refers to the full range of processes and mechanisms that support thinking, and also the content or products of these processes, namely thoughts themselves. The basic premise of cognitive theories of emotional disorder is that dysfunction arises from an individual’s interpretation of events. Moreover, behavioural responses emerging from particular interpretations are also important factors involved in the maintenance of emotional problems.

Ellis’s (1962) cognitive approach is based on the principle that ‘irrational beliefs’ are the source of disturbed emotional and behavioural consequences. These beliefs predominantly consist of unconditional shoulds, musts, commands and demands which lead to illogical cognitions and emotional disturbances. Ellis (1962) initially documented 11 beliefs which he considered predisposed to negative emotional reactions. For example: ‘A person must be perfectly competent, adequate and achieving to be considered worth while; it is essential that a person be loved or approved of by virtually everyone in the community’. Because these belief systems are reinforced by society, by self-indoctrination, and may even have an inherited basis, they should be disputed vigorously in therapy.

Beck’s cognitive theory of emotional disorders (Beck, 1967; 1976) asserts that emotional disorders are maintained by a ‘thinking disorder’ in which anxiety and depression are accompanied by distortions in thinking. Dysfunctional processing of this kind is manifest at a surface level as a stream of negative automatic thoughts in the patient’s consciousness. Distortions in processing and negative automatic thoughts reflect the operation of underlying beliefs and assumptions stored in memory. Beliefs and assumptions are relatively stable representations of knowledge stored in memory structures that cognitive psychologists have termed schemas (Bartlett, 1932). Once activated schemas influence information processing, shape the interpretation of experience, and affect behaviour. While the behaviour or thinking of an anxious individual may superficially seem ‘irrational’ it is derived logically from the beliefs and assumptions held. Dysfunction in information processing in emotional disorder is evident in the patient’s beliefs, cognitive distortions, and negative automatic thoughts.

COGNITIVE THEORY OF ANXIETY DISORDERS

In anxiety disorder the disturbance in information processing which underlies anxiety vulnerability and anxiety maintenance can be viewed as a preoccupation with or ‘fixation’ on the concept of danger, and an associated underestimation of personal ability to cope (Beck, Emery & Greenberg, 1985). The theme of danger in anxiety is evident in the content of anxious schemas (i.e. assumptions and beliefs) and the content of negative automatic thoughts. The predominance of danger-related thoughts in the stream of consciousness of anxiety patients (e.g. Beck, Laude & Bohnert, 1974a; Hibbert, 1984; Rachman, Lopatka & Levitt, 1988), contrasts with the themes of loss and self-devaluation in depressive negative automatic thoughts (e.g. Beck, Rush, Shaw & Emery, 1979; Beck, 1987), and is the basis of the content-specificity hypothesis in which anxiety and depression are distinguishable in terms of thought content.

The overestimation of danger and underestimation of ability to cope with situations in anxiety disorder reflects the activation of underlying danger schemas: ‘The locus of the disorder in the anxiety states is not in the affective system but in the hypervalent cognitive schemas relevant to danger that are continually presenting a view of reality as dangerous and the self as vulnerable’ (Beck, 1985, p. 192). Once danger appraisals are activated a number of vicious circles maintain anxiety. Particular anxiety symptoms may themselves pose a threat. For example, they may impair performance or be interpreted as a sign of serious physical or mental disorder. These effects increase the subjective sense of vulnerability, and as appraisals of danger increase so do primal anxiety responses which in turn contribute to unfavourable responses and appraisals, and so on.

Dysfunctional schemas

The term schema refers to a cognitive structure. However, in the schema theory of emotional disorder it is the content of these structures which is given most consideration. Two types of informational content or knowledge at the schema level are considered in Beck’s theory: beliefs and assumptions. Beliefs are ‘core’ constructs that are unconditional in nature (e.g. ‘I’m a failure; I’m worthless; I’m vulnerable; I’m inferior’), and are taken as truths about the self and the world. Assumptions are conditional and may be thought of as instrumental, insomuch as they represent contingencies between events and self-appraisals (e.g. ‘if I show signs of anxiety then people will think I’m inferior; having bad thoughts means I am a bad person; unexplained physical symptoms are usually a sign of serious illness; if I can’t control anxiety I am a complete failure’). Beliefs are typically expressed as unconditional self-relevant statements (e.g. ‘I am a failure’), whereas assumptions are expressed as ‘if-then’ propositions (e.g. if I show signs of anxiety then everyone will reject me’).

The maladaptive schemas that characterise emotional disorder are hypothesised as more rigid, inflexible and concrete than schemas of normal individuals (Beck, 1967). The content of a schema is purported to be specific to a disorder. Therefore, anxiety schemas contain assumptions and beliefs about danger to one’s personal domain (Beck et al., 1985) and of one’s reduced ability to cope. Specific models of disorders such as panic (Clark, 1986), Social phobia (Clark & Wells, 1995), and Generalised Anxiety Disorder (Wells, 1995), identify more specific themes in appraisal and schemas associated with problem maintenance. In generalised anxiety, for example, a disorder characterised by chronic worry, beliefs about general inability to cope, and positive and negative beliefs about worrying itself, have been implicated (Wells, 1995). In panic disorder, in which patients show a tendency to misinterpret bodily sensations in a catastrophic way, appraisals and assumptions concerning the dangerous nature of anxiety symptoms and other bodily events predominate (Clark, 1986). In the specific phobias individuals associate a situation or object with danger and hold assumptions concerning the negative events that could occur when exposed to the phobic stimulus (Beck et al., 1985).

Although dysfunctional assumptions and beliefs may form as a result of early experience this is not always the case. In panic disorder, for example, dysfunctional assumptions may not pre-date the first panic attack, but may develop as a consequence of how the attack was dealt with (Clark, personal communication). If, for example, the individual is led to believe that panic attacks can lead to negative events such as fainting, or the person is presented with ambiguous information concerning his or her state of health, dysfunctional assumptions are likely to be established. In generalised anxiety, patients seem to hold positive and negative beliefs about worrying (Wells, 1995). Positive beliefs in some cases are derived from early experience, and negative beliefs about worrying only develop after an extended time period, perhaps when attempts to control worry seem impaired. In social phobia, some patients may function well most of their lives but develop specific negative assumptions about the social self only after they fail to meet up to personal rules for social self-regulation (Clark & Wells, 1995; Wells & Clark, 1997). In other cases negative beliefs about the social self may be longstanding and are associated with shyness and timidity since childhood.

Assumptions or ‘rules’ in anxiety influence the conclusions individuals draw from situations and also the manner in which they behave. For example, a socially anxious patient with the assumption ‘Showing anxiety will lead people not to take me seriously’ may reach the conclusion ‘I had better say as little as possible in order to conceal my anxiety’; this may lead to the self-instruction ‘Don’t say a lot; try and look relaxed’. In this scenario the linkages between assumptions, situational appraisals and behavioural imperatives are observable. As discussed later in this chapter, behavioural responses emerging from dysfunctional appraisals and assumptions are often involved in the maintenance of belief in danger appraisals, assumptions, and beliefs (Salkovskis, 1991; Wells et al., 1995b).

Negative automatic thoughts, worries and obsessions

The content of cognition in emotional disorders has been given various labels, such as automatic thoughts (Beck, 1967), self-statements (Meichenbaum, 1977), and worry (Borkovec, Robinson, Pruzinsky & De Pree, 1983a). In Beck’s schema theory of anxiety, negative automatic thoughts represent the surface cognitive features of schema activation. Negative automatic thoughts (NATs) are appraisals or interpretations of events, and can be tied to particular behavioural and affective responses. A strong cognitive position would argue that negative automatic thoughts cause anxiety, however, in schema theory they are considered to reflect cognitive mechanisms that modulate and maintain anxiety.

The description of negative automatic thoughts provided by Beck and colleagues (e.g. Beck et al., 1985) suggests that they are rapid negative thoughts that can occur outside of the focus of immediate awareness although they are amenable to consciousness. They occur in verbal or imaginal form, and are believable at the time of occurrence. Distinctions can be made between different types of thought in anxiety disorders. More specifically, negative automatic thoughts can be distinguished from worry, and obsessions. Wells (1994a) suggests that it may be useful to distinguish between all these varieties of thought. For example, negative automatic thoughts can be distinguished from worry, and both worry and negative automatic thoughts can be distinguished from obsessions (Wells, 1994a; Wells & Morrison, 1994) . Worry is described by Borkovec and colleagues (Borkovec et al., 1983) as a chain of negatively affect laden thoughts aimed at problem solving. Borkovec et al. (1983a) contend that worry is predominantly a verbally based thought process; however, negative automatic thoughts can occur in a verbal and an imaginal form. Obsessions tend to be of shorter duration than worries, but most relevant of all they are ego-dystonic whereas worries and NATs are not—that is, they are experienced as senseless and alien to the self-concept. For example, a mother may have thoughts of harming her newborn baby although she has no desire to do so. In general, NATs and worries represent appraisals of events in cognitive models of anxiety, while obsessions are intrusive mental experiences that are the focus of appraisals. Obsessions occur as urges or impulses as well as thoughts (e.g. Parkinson & Rachman, 1981). Worries are normal phenomena (Wells & Morrison, 1994), as are obsessions (Rachman & de Silva, 1978; Salkovskis & Harrison, 1984), and automatic thoughts are also likely to be a normally occurring type of cognition. Wells and Morrison (1994) compared the attributes of normally occurring worries and obsessions over a two-week period in non-patient subjects. Their data showed significant self-rated differences between these two types of thought. Worries were rated as significantly more verbal and obsessions as more imaginal; worries were also of longer duration (overall mean = 9 minutes for worries and 2 minutes for obsessions), worries were less involuntary, and more realistic than obsessions. These data suggest that distinctions between different types of thought are possible. In Chapters 8 and 10 the theoretical and practical relevance of potential distinctions is considered in detail.

The role of behaviour

When a danger appraisal is made the cognitive system facilitates caution by eliciting a series of self-doubts, negative evaluations, and negative predictions. The somatic manifestation of this consists of a range of feelings such as unsteadiness, faintness, and weakness. Beck et al. (1985) assume that this is part of a primal survival mechanism that exists to terminate risk-taking behaviour and orient behaviour towards self-protection. In some circumstances such as social performance situations these responses can increase the danger they are designed to avert (i.e. they interfere with social performance).

Apart from automatic and reflexive anxiety responses highlighted in the schema model, behavioural reactions that are more volitional in nature are an important influence in the maintenance of dysfunction. Wells and Matthews (1994) suggest that many of the cognitive and behavioural responses to threat reflect strategies or plans of action that are actively (at least initially) executed and modified by the individual to protect against danger. Unfortunately some of these responses are counterproductive because they maintain preoccupation with threat and prevent unambiguous disconfirmation of dysfunctional thoughts and assumptions (Salkovskis, 1991; Wells et al., 1995b). For example, a social phobic fearful of babbling and talking incoherently in a social situation may focus more attention on the self and monitor his/her spoken words closely. In addition to this cognitive selfmonitoring strategy there may be attempts to pronounce words in a clear and controlled way, and rehearse mentally the material to be spoken before speaking in order to check that it sounds acceptable. These subtle and covert responses constitute ‘safety behaviours’ (Salkovskis, 1991) that are intended to avert feared events. Safety behaviours play a significant role in the maintenance of anxiety. For example, a person having a panic attack who believes that a catastrophe such as fainting is imminent is likely to engage in behaviour designed to prevent the catastrophe, such as sitting down or trying to relax. Whilst the behaviour may relieve anxiety it unintentionally preserves the belief in the catastrophe. Under these conditions each panic becomes an example of a ‘near-miss’ rather than a disconfirmation of belief, and danger may seem subsequently more evident. In some instances safety behaviours not only prevent exposure to disconfirmatory experiences, but exacerbate symptoms in a way that enhances belief in danger appraisals. In social phobia, attempts to monitor one’s own speech and mentally censor sentences before saying them interferes with processing important aspects of the situation and interferes with subjective verbal fluency, thereby contributing to appraisals of poor performance (e.g. Wells et al., 1995b). Similarly, attempts to suppress certain types of thought, have been shown to increase the frequency of the unintended thought (Wegner, Schneider, Carter & White, 1987). This effect has implications for disorders characterised by unwanted intrusive thoughts, in particular obsessional problems and generalised anxiety disorder. In these cases individual attempts to control or suppress obsessions or worries may exacerbate these thoughts. In summary, it is likely that safety behaviours maintain anxiety via a number of pathways:

1. Safety behaviours exacerbate bodily symptoms — an effect that may be interpreted as evidence for feared catastrophes. For example, controlling one’s breathing may lead to hyperventilation and the symptoms associated with respiratory alkalosis. Controlling certain thoughts may contribute to paradoxical effects of increased preoccupation with thoughts and concomitant diminished appraisals of control.

2. The non-occurrence of feared outcomes can be attributed to the use of the safety behaviour rather than correctly attributed to the fact that catastrophe will not occur.

3. Particular safety behaviours, such as increased vigilance for threat, reassurance seeking, etc., enhance exposure to danger-related information that strengthens negative beliefs. For example, the health-anxious patient may seek reassurance from numerous medical consultations, increasing the likelihood of exposure to contradictory and ambiguous information. This information may then be interpreted as evidence that ‘doctors tend to miss serious illness’ which strengthens danger appraisals and disease conviction.

4. Safety behaviours may contaminate social situations and affect interactions in a manner consistent with negative appraisals. The social phobic who elects to say little about the self and avoid eye contact in order to reduce a risk of appearing ‘foolish’ is difficult to make conversation with. This may lead people to interact less with the social phobic and exclude them from conversation. This effect could then be interpreted by the social phobic as evidence that people really think he or she is foolish. Wells et al. (1995b) document a range of safety behaviours tied to specific fears of social phobics (see Chapter 7 and the rating scales in the Appendix for examples).

Cognitive biases

Once activated, danger schemata introduce biases in the processing of information. These biases are often distortions that affect interpretations of events in a way that is consistent with the content of dysfunctional schemas. As a result, negative beliefs and appraisals are maintained. Biases in processing include attentional phenomena such as selective attention for threat-related material, and biases in the interpretation of events.

Beck and associates, and Burns (1989) have labelled a range of interpretive biases as ‘thinking errors’ or ‘cognitive distortions’ (Beck et al., 1979, 1985; Beck, 1967; Burns, 1989). Common errors or distortions include the following:

• Arbitrary inference: Drawing a conclusion in the absence of sufficient evidence.
• Selective abstraction: Focusing on one aspect of a situation while ignoring more important (and more relevant) features.
• Overgeneralisation: Applying a conclusion to a wide range of events or situations when it is based on isolated incidents.
• Magnification/minimisation: Enlarging or reducing the importance of events. Minimisation is similar to discounting the positives—insisting that positive experiences don’t count.
• Personalising: Relating external events to the self when there is no obvious basis to do so.
• Catastrophising: Dwelling on the worst possible outcome of a situation and overestimating the probability that it will occur.
• Mind reading: Assuming people are reacting negatively to you when there is no definite evidence for this.

To illustrate how cognitive biases can maintain belief in negative interpretations, consider the example of a socially phobic person involved in a conversation with a work colleague. The colleague suddenly cuts short the conversation and leaves the situation. The social phobic may interpret this as: ‘I must be so boring’ or ‘he thinks I’m an idiot, he doesn’t like me’. These appraisals are examples of ‘arbitrary inference’ and ‘mind reading’. In the next encounter with the colleague the social phobic is pre-occupied with negative thoughts about ‘appearing boring and idiotic’, he/she selectively attends to his/her own anxious performance, and fails to notice positive signals from the work colleague, or discounts these as evidence that he is ‘just trying to be nice’. In this example biases of attention and inference serve to maintain belief in negative appraisals, as negative information is abstracted, and positive information is not processed, or is discounted.

SUMMARY OF THE GENERAL SCHEMA THEORY

The central principles of schema theory of anxiety were outlined in the previous sections. In summary, anxiety is associated with appraisals of danger. Some individuals are more susceptible to appraising situations as dangerous because they possess schemas containing information about the dangerous meaning of situations and about their diminished ability to deal effectively with threat. Once ‘danger schemas’ are activated, appraisals are characterised by negative automatic thoughts about danger. These thoughts reflect themes of physical, social or psychological catastrophes directly or indirectly involving the self. Biases in processing associated with schema activation maintain belief in negative automatic thoughts, assumptions and beliefs by distorting interpretations in a manner that is consistent with dysfunctional beliefs and appraisals. Individuals typically try to reduce danger through their behavioural responses of avoidance or safety-behaviours. These behaviours cause their own problems in anxiety disorders by intensifying anxiety symptoms, and preventing disconfirmation of belief in danger cognitions. The basic features of this generic cognitive theory are depicted diagrammatically in Figure 1.0.

Figure 1.0 Generic cognitive theory of anxiety disorder

EVIDENCE FOR THE SCHEMA THEORY OF ANXIETY

Predictions based on schema theory have been tested with a range of paradigms: interviews, questionnaires, and information-processing tasks. Early work on the nature of automatic thoughts in anxiety focused on the content of appraisals in patients with anxiety neurosis—a disorder category now outmoded but one that consisted of both panic and generalised anxiety disorder. Beck et al. (1974) conducted open-ended interviews with patients with anxiety and showed that all patients reported the experience of thoughts and/or visual fantasies concerned with themes of death, disease, and social humiliation occurring just prior to or during anxiety attacks. Hibbert (1984) replicated this finding with generalised anxiety or panic patients, and concluded that thoughts in panic could be understood as a reaction to somatic symptoms. Patients reported that their thoughts were more credible, more intrusive, and harder to dismiss when anxiety was most severe. Ottaviani and Beck (1987) showed that patients with panic disorder had thoughts about physical catastrophes such as dying, having a heart attack, suffocating and having a seizure. However, patients also feared psychological catastrophes such as losing control or going crazy. Almost half of the patients also feared social humiliation as a result of appraised physical or mental catastrophes. Rachman et al. (1988) exposed panic patients to their feared situation and obtained similar thoughts concerning personal catastrophe. These data combined with results from similar studies (see Wells, 1992, for review) provide evidence consistent with a central prediction of schema theory that anxiety disorders are associated with negative thoughts about danger. Moreover, depression can be differentiated from anxiety by the predominance of particular types of cognition. In depression negative thoughts are predominantly concerned with themes of loss and selfdevaluation while in anxiety themes of danger predominate (Beck, Brown, Steer, Eidelson & Riskind, 1987). There are, of course, limitations with self- report data of this kind; it may be contaminated by subjects ability to report covert events, by the accuracy of memory processes or by demand characteristics. However, a source of evidence for schema theory comes from the use of more objective measures of cognitive p...