Cognitive behaviour therapy for anxiety disorders

Abstract

Abstract Cognitive behaviour therapy for anxiety disorders is a brief psychological treatment (1 to 16 sessions), based on the cognitive model of emotional disorders. Within this model, it is assumed that it is not events per se, but rather people's expectations and interpretations of events, which are responsible for the production of negative emotions such as anxiety, anger, guilt, or sadness. In anxiety, the important interpretations, or cognitions, concern perceived physical or psychosocial danger. In everyday life, many situations are objectively dangerous. In such situations, individuals’ perceptions are often realistic appraisals of the inherent danger. However, Beck argues that in anxiety disorders, patients systematically overestimate the danger inherent in certain situations, bodily sensations, or mental processes. Overestimates of danger can arise from distorted estimates of the likelihood of a feared event, distorted estimates of the severity of the event, and/or distorted estimates of one's coping resources and the availability of rescue factors. Once a stimulus is interpreted as a source of danger, an ‘anxiety programme’ is activated. This is a pattern of responses that is probably inherited from our evolutionary past and originally served to protect us from harm in objectively dangerous primitive environments (such as attack from a predator). The programme includes changes in autonomic arousal as preparation for flight/fight/fainting and increased scanning of the environment for possible sources of danger. In modern life, there are also situations in which these responses are adaptive (such as getting out of the path of a speeding car). However, when, as in anxiety disorders, the danger is more imagined than real, these anxiety responses are largely inappropriate. Instead of serving a useful function, they contribute to a series of vicious circles that tend to maintain or exacerbate the anxiety disorder. Two types of vicious circle are common in anxiety disorders. First, the reflexively elicited somatic and cognitive symptoms of anxiety become further sources of perceived danger. For example, blushing can be taken as an indication that one has made a fool of oneself, and this may lead to further embarrassment and blushing; or a racing heart may be taken as evidence of an impending heart attack and this may produce further anxiety and cardiac symptoms. Second, patients often engage in behavioural and cognitive strategies that are intended to prevent the feared events from occurring. However, because the fears are unrealistic, the main effect of these strategies is to prevent patients from disconfirming their negative beliefs. For example, patients who fear that the unusual and racing thoughts experienced during panic attacks indicate that they are in danger of going mad and often try to control their thoughts and (erroneously) believe that if they had not done so, they would have gone mad. Within cognitive models of anxiety disorders, at least two different levels of disturbed thinking are distinguished. First, negative automatic thoughts are those thoughts or images that are present in specific situations when an individual is anxious. For example, someone concerned about social evaluation might have the negative thought, ‘They think I'm boring’, while talking to a group of acquaintances. Second, dysfunctional assumptions are general beliefs, which individuals hold about the world and themselves which are said to make them prone to interpret specific situations in an excessively negative and dysfunctional fashion. For example, a rule involving an extreme equation of self-worth with social approval (‘Unless I am liked by everyone, I am worthless’) might make an individual particularly likely to interpret silent spells in conversation as an indication that others think one is boring. Cognitive behaviour therapy attempts to treat anxiety disorders by (a) helping patients identify their negative danger-related thoughts and beliefs, and (b) modifying these cognitions and the behavioural and cognitive processes that normally maintain them. A wide range of procedures are used to achieve these aims, including education, discussion of evidence for and against the beliefs, imagery modification, attentional manipulations, exposure to feared stimuli, and numerous other behavioural assignments. Within sessions there is a strong emphasis on experiential work and on working with high affect. Between sessions, patients follow extensive homework assignments. As in cognitive behaviour therapy for other disorders, the general approach is one of collaborative empiricism in which patient and therapist view the patient's fearful thoughts as hypotheses to be critically examined and tested.