Treatment Resistant Anxiety Disorders

Resolving Impasses to Symptom Remission

Deborah Sookman, Robert L. Leahy, Debbie Sookman, Robert L. Leahy, Deborah Sookman, Debbie Sookman, Robert L. Leahy

• Publisher: Routledge
• Year: 2009
• Print ISBN: 9780415988919
• eBook ISBN: 9781135858353
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

Treatment Resistant Anxiety Disorders: Resolving Impasses to Symptom Remission brings together leading cognitive behavioral therapists from major theoretical orientations to provide clinicians with a greatly needed source of information, skills, and strategies from a wide range of CBT approaches.

It describes how to combine empirically-based findings, broad based and disorder specific theoretical models, and individualized case conceptualization to formulate and apply specific strategies for varied aspects of resistance during treatment of anxiety disorders.

chapter one

Metacognitive therapy

Application to generalized anxiety disorder

Adrian Wells

University of Manchester
Manchester, United Kingdom

Contents

Understanding GAD

The model in action

Metacognitive therapy

A case illustration

Empirical status of MCT

Empirical status of treatment

MCT in wider

Conclusion

References

A central premise of metacognitive theory and therapy (Wells, 2000) is that the control of thought processes determines how long mental suffering lasts. More specifically, sustained processing determines unwanted and extended emotions. In metacognitive theory, the content of thoughts is not seen as central in causing psychological disorder, but the extent to which individuals engage in a specific style of thinking is crucial.

Metacognitive therapy (MCT) (Wells, 1995, 2009) is based on the self-regulatory executive function (S-REF) model (Wells & Matthews, 1994, 1996). A basic principle is that periods of negative thoughts, distressing beliefs, and negative emotions are quite common and normal human experiences, but these inadvertently become elaborated and extended because of the style of a person’s subsequent cognition and coping. Disorder is caused (in the sense that it persists) by a toxic style of thinking called the cognitive attentional syndrome (CAS), which is the product of metacognition.

Before describing in detail the nature of the CAS, we should examine first what is meant by the term “metacognition.”

Metacognition is a domain of cognition that is responsible for the regulation and appraisal of thinking. It is cognition applied to cognition and probably involves some discrete architecture, mechanisms, and processes. The field of metacognitive inquiry arose in the context of developmental psychology and memory research (e.g., Brown & McNeill, 1966; Flavell, 1979; Nelson & Narrens, 1990) but remained largely unexplored as an area of fruitful study for understanding psychological disorders.

This situation changed with the advent of the self-regulatory executive function (S-REF) model, which offered a metacognitive account of the development and maintenance of psychological disorder (Wells & Matthews, 1994, 1996). In the S-REF theory, all psychological disorders can be linked to the activation of a style of thinking known as the CAS. This consists of three components: (1) a preponderance of verbal conceptual activity in the form of worry and rumination, (2) the tendency to maintain attention on sources of threat, and (3) coping behaviors that disrupt self-regulation or the acquisition of new information that can modify erroneous knowledge.

The CAS essentially represents the person’s response to internal events and is a specific constellation of cognitive and behavioral coping styles. Although the volitional nature of this style remains intact, the person’s awareness or knowledge of control and volition over processes such as worry and rumination is often incomplete or erroneous. The initiation of such processes can be reflexive, but sustained processing in the form of worry or rumination is under voluntary control.

Worrying is comprised of long chains of verbal thoughts in which the person seeks answers to questions about how to cope with or avoid potential danger. It is epitomized by triggering thoughts such as “What if I have an accident?” and is followed by an extended inner dialogue in which the person attempts to generate answers. Rumination is a similar conceptual process, but it tends to be past oriented and seeks reasons for failing and ways of understanding and dealing with feelings of sadness and loss.

Another aspect of the CAS, threat monitoring, refers to maintaining attention on sources of threat. These may be internal, such as bodily sensation in panic disorder or an impression of the self in social phobia, but they may also be external, such as looking for signs of dirt or contamination in obsessive–compulsive disorder (OCD), or scanning the environment for potential sources of danger in posttraumatic stress disorder (PTSD).

The third constituent of the CAS is other coping or self-regulatory behaviors, including avoidance, using substances to control thoughts and emotions, and more direct attempts to suppress thoughts. These strategies may provide short-term relief from suffering, but they fail to provide a long-term solution. Indeed, they are prone to backfire and maintain or contribute further to stress. For example, thought suppression is not consistently effective and may contribute to fears of loss of control. Strategies such as avoidance remove the opportunity to learn that emotions or situations are safe. Strategies such as alcohol use can have negative physical and social consequences.

What are the other mechanisms linking the CAS to prolonged emotional suffering? Worry and rumination are a problem because they prolong anxiety and negative affect by focusing on danger or by extending thoughts about failure, loss, and sadness. For example, a depressed patient undergoing metacognitive therapy explained how he would analyze reasons for feeling sad in an attempt to find a way to improve his mood. Unfortunately, he was unable to find a cause and concluded he was weak and defective for being like this. Similarly, a patient with PTSD who had been involved in a traffic accident reported that she worried about bad things that could happen in the future because she wanted to avoid them. As a result, she had begun to notice how unsafe the environment was and how much potential there was for danger. This increased her sense of vulnerability and maintained her anxiety when traveling away from home.

Worry and rumination can interfere with other in-built processes necessary for emotional processing and regulating lower level cognitive activity. They use processing resources leading to a reduction in resources that are necessary for executive control of cognition. Worry and rumination continuously present threat-related information to consciousness and maintain the sense of current danger and the anxiety program that accompanies it. Such effects are likely to be dependent on prefrontal modulation of activity in fear and emotion networks in the limbic brain.

Threat monitoring is problematic because it enhances perceptions of danger, thereby increasing the activation of anxiety responses. Many of the threats in emotional disorder are “tentative” in nature and represent “potential threats.” For example, the person with obsessive–compulsive disorder scans the environment for possible signs of contaminants, and the individual with hypochondriasis checks his body for unusual signs that could indicate serious illness. As a consequence, normal benign environmental or internal events appear more dangerous and the person feels more vulnerable.

Other coping behaviors are problematic in several ways. Selfregulatory strategies such as trying to suppress thoughts are not particularly effective and may increase intrusions or maintain awareness of unwanted thoughts (Wegner, 1997; Wegner, Schneider, Carter, & White, 1987). However, even when suppression is successful, it can prevent the person from developing a healthier and more flexible relationship with his own cognitions. Thus, the person does not discover that thoughts are simply passing internal events that are unimportant. For example, the person with obsessive–compulsive symptoms believes that some thoughts can cause harm, and successful suppression or neutralization prevents the individual from discovering that thoughts alone have no real influence. Thus, an appropriate and more adaptive metacognitive awareness and model of internal mental experiences is not acquired or strengthened.

Behaviors such as avoidance or saving oneself from threat backfire because they deprive the person of an opportunity to discover that threat is erroneous or that they can cope effectively. For example, an individual with social phobia who mentally rehearses sentences before speaking in order to avoid appearing foolish does not learn that his spontaneous speech does not attract such derision. Moreover, mental rehearsal impedes spontaneity and appropriate attention to the social task. Strategies such as using substances or seeking reassurance are a problem because they can have an adverse interpersonal effect that contributes to relationship pressures and further stress.

As the forgoing describes, the CAS presents a problem in that it compounds and extends dysfunctional ideas and emotional distress. This syndrome arises out of metacognitions, of which two general content categories are identified in the metacognitive model: positive and negative metacognitive beliefs. Positive metacognitive beliefs concern the advantages of engaging in components of the CAS and include beliefs about worry, rumination, threat monitoring, and controlling or avoiding thoughts and emotions. For instance, the person believes: “Focusing on possible threats means I’ll be able to remain safe,” or “Worrying about harmful events means I won’t be taken by surprise,” or “Analyzing why I feel so bad will help me overcome my depression.” Negative metacognitive beliefs concern the uncontrollability, importance, and danger of thoughts. Examples of these beliefs include: “I have no control over my thinking,” or “My thoughts mean I’m losing my mind,” or “Some thoughts have the power to make bad things happen.”

In particular disorders, it is possible to identify some specificity in these categories. In depression, positive beliefs primarily concern the advantages of rumination, whereas in generalized anxiety disorder (GAD) they concern the advantages of using worry as a coping strategy. In OCD, positive beliefs concern the advantages of worrying as a means of preventing the dangerous consequences of thoughts or preventing contact with possible contamination. Positive beliefs in OCD also include the benefits of engaging in rituals and neutralizing responses in response to obsessions. In PTSD, they concern the advantages of worrying about threats in order to remain safe and the benefits of recounting aspects of the trauma to find answers about causality. As we will see later, positive beliefs in GAD focus on worry as a means of effectively avoiding or dealing with danger in the future.

As for negative beliefs in OCD, these concern “fusion” domains in which the individual believes thoughts have special power or significance to cause negative outcomes. The term thought–action fusion (TAF) was introduced by Rachman (1993) in his description of cognitive distortions in OCD. He distinguished probability and morality variants of TAF in which the individual appraises the occurrence of a thought as being morally equivalent to performing an action or as increasing the probability of an occurrence. The metacognitive model of OCD (Wells, 1997) maintains this terminology but views fusion as a series of interrelated metacognitive beliefs, labeled thought–event fusion (TEF), thought–action fusion (TAF), and thought–object fusion (TOF). With TEF, the person believes that certain thoughts can cause events (e.g., “thinking about an accident will make it happen”). With TAF the belief is that thoughts will cause the commission of unwanted acts (e.g., “thinking about stabbing someone will make me do it”). With TOF, the belief is that thoughts and feelings can be transferred into objects (e.g., “having bad thoughts will contaminate objects I touch”).

In depression and PTSD, negative beliefs focus on the uncontrollability of worry and rumination and the meaning of intrusions (e.g., “recurrent thoughts about the trauma mean I’m losing my mind”). In GAD, as we will see later, these beliefs concern the uncontrollability of worry and its dangerous effects on physical and mental functioning.

In the above description of metacognitive beliefs, I have presented them as symbolic and propositional representations, but alternative forms of metacognitive knowledge are important in the S-REF model. Much of the knowledge on which processing draws is not directly verbally expressible and is thought to exist as metacognitive plans or programs for controlling attention, memory, and low-level, emotion-related processing. These can be likened to thinking skills acquired through experiencing executive control. Unfortunately, flexible executive control is often constrained in psychological disorders because of an over-reliance on metacognitions that support the CAS. An implication of this multicomponent view of knowledge is that treatment should aim to enhance flexible control over processing and not simply interrogate the nature of automatic thoughts and more general (nonmetacognitive) schemas.

Understanding GAD

By now it is well established that GAD is responsive to cognitive–behavioral treatments (CBT), but treatment outcomes are variable and modest. Treatment comprised of applied relaxation, anxiety management, and cognitive–behavioral interventions shows a wide range of efficacy rates. At worst, 0% of patients show recovery on the basis of standardized criteria applied to trait–anxiety outcome scores, while at best the rate is 63% at posttreatment (Fisher, 2006). The aggregated recovery rate across studies of CBT is 46% at posttreatment assessed by trait–anxiety and 48% as assessed by the Penn State Worry Questionnaire (Fisher, 2006). These statistics show that there is much ground for improvement.

One of the difficulties facing the clinician in treating GAD is that the content of worry changes which reduces the overall effectiveness of strategies focused primarily on reality testing individual worries. What is required is a model of the factors that give rise to the repeated and difficult-to-control worry process that is a hallmark of GAD, irrespective of the content of that process. The metacognitive approach is an obvious choice.

The metacognitive approach to GAD (Wells, 1995; Wells et al., 2008) makes an important distinction between negative thoughts and sustained processing in the form of worry. Worry is seen as a coping response of sustained thinking in response to negative thoughts. A worry episode is triggered by a negative thought that typically occurs as a “what if?” question and occasionally as a mental image. For example, the person prone to pathological worry may think, on overhearing a conversation about illness, “What if my children become ill?” For most people, a thought of this kind will be dismissed as simply a negative idea; however, those with GAD are less flexible in their choice of thinking strategy and this thought is superseded by chains of negative conceptual activity in the form of worry aimed at assessing a range of negative outcomes and planning ways of dealing with them. The worry sequence might go something like this: “What if my daughter gets ill? It probably won’t be serious. But what if it is? I’ve heard reports of meningitis recently. What if she catches that? It’s unlikely to happen, but what if she does? I’d better keep a lookout for any symptoms. What should I look for? She’s had a cough recently. What if she has a chest infection? Maybe I shouldn’t ignore it. What if it’s serious? I should make an appointment with the doctor. What sort of mother will they think I am for leaving it? What if she has spread it to her classmates? …”

The consequence of worry is that it prolongs and intensifies anxiety. Anxiety and worry persist until displaced by competing goals or distractors, or until the person appraises that the “work of worry” is complete. Typically, internal and inappropriate stop signals exist for worry. For example, some patients worry until they feel confident that they can cope or until they are reassured that there is nothing to worry about. The worry sequence has deleterious consequences for emotional well-being. It p...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• Contributors
• Introduction
• Chapter 1. Metacognitive therapy: application to generalized anxiety disorder
• Chapter 2. Specialized cognitive behavior therapy for treatment resistant obsessive compulsive disorder
• Chapter 3. Treatment for complex PTSD
• Chapter 4. Understanding and managing treatment-resistant panic disorder: perspectives from the clinical experience of several expert therapists
• Chapter 5. Emotional schemas in treatment-resistant anxiety
• Chapter 6. Augmenting exposure-based treatment for anxiety disorders with principles and skills from dialectical behavior therapy
• Chapter 7. Combining motivational interviewing and cognitive-behavioral therapy to increase treatment efficacy for generalized anxiety disorder
• Chapter 8. Using a compassionate mind to enhance the effectiveness of cognitive therapy for individuals who suffer from shame and self-criticism
• Chapter 9. Suggestions from acceptance and commitment therapy for dealing with treatment-resistant obsessive-compulsive disorder
• Chapter 10. Treating anxiety disorders in the context of concurrent substance misuse
• Chapter 11. The pharmacotherapy of treatment-resistant anxiety disorders in adults in the setting of cognitive-behavioral therapy
• Chapter 12. Conclusions
• Index