Robert A. DiTomasso, Ph.D., ABPP
Arthur Freeman, Ed.D., ABPP
Raymond Carvajal, M.A.
Bruce Zahn, Ed.D., ABPP
I
t would be virtually impossible to conceive of living without experiencing concerns for safety, well-being, or security at some point during the life cycle. These con- cepts derive from a common concern for anticipated ad- verse consequences embodied in the cognitive issue of what has been termed the “What if…” phenomenon. In the biological realm, an important matter for any organ- ism is the extent to which the nutrients on which sur- vival hinges can be obtained. In the emotional realm, being free from assault or harm to one’s physical well- being or sense of self-esteem is critical. Thus, percep- tion of safety plays a crucial role, because without it, the organism would be in a constant state of anxiety or arousal and prepared for fight-or-flight responses. The cognitive realm encompasses the thoughts, attitudes, beliefs, assumptions, and images that guide feelings and behaviors. In theorizing and attempting to understand the human condition, including the experience of anxi- ety, the cognitive realm, which was traditionally largely ignored, has gained more attention through its inclu- sion as part of a model for understanding anxiety (Bar- low 2002; Foa and Kozak 1986; Lang and McNeil 2006; Nemeroff et al. 2006; Shafran and Rachman 2004).Over the past three decades, the field of psychology has undergone a cognitive revolution (Beck 1991, 2005; Mahoney 1974; Meichenbaum 1977). This cognitive or, more aptly termed, cognitive-behavioral revolution has been energized by the interaction among several factors, including the needs of clinical practice, the ex- perimental tradition of behavioral psychology, account- ability, and the demand for evidenced-based interven- tions. This vital interaction has yielded a theoretical model that has produced several empirically supported treatments, a major part of which has been the develop- ment and refinement of cognitive-behavioral strategies and techniques (Leahy 2003). Although some debate remains about the relative primacy of behavioral or cog- nitive approaches (Beck 1991; Simon and Fleming 1985), the therapeutic mix is arguably dependent on the specific goals of therapy, the skills of the patient, and the skills of the therapist (Freeman et al. 1990). To date, cognitive-behavioral therapy (CBT) has been demon- strated to be effective in treating such anxiety conditions as generalized anxiety disorder, posttraumatic stress dis- order, social phobia, and childhood anxiety disorders (A.C. Butler et al. 2006). It has also been indicated in the treatment of panic disorder with or without
agoraphobia (Friedman et al. 2006), late-life general- ized anxiety disorder (Stanley et al. 2003), and comor- bid generalized anxiety disorder and panic disorder with agoraphobia (Labrecque et al. 2006). Moreover, treat- ment gains with CBT for anxiety tend to endure follow- ing treatment termination (Hollon et al. 2006), and ev- idence-based treatments for anxiety disorders, featuring CBT, are to found to be more cost-effective (Myhr and Payne 2006).
The earliest roots of the role and importance of cog- nition in human behavior can be traced to Eastern, Greek, and Roman philosophers (Beck and Weishaar 1989) and the early work of George Kelly (1955). There is little doubt, however, that the theories of Albert Ellis (1962) and Aaron T. Beck (1967) have been the most in- fluential sources in creating, guiding, and nurturing the cognitive movement. The so-called Third Wave cogni- tive-behavioral therapies, including Acceptance and Commitment Therapy (ACT; Hayes and Pierson 2005) and Mindfulness-Based Cognitive Therapy (MBCT; Baer 2003), are rapidly gaining in popularity.
In this chapter, we outline and discuss the cognitive- behavioral theory and model of anxiety and anxiety dis- orders. We address the definition of anxiety and anxiety disorders; basic assumptions of the cognitive-behavioral theory of anxiety; the role of predisposing and precipi- tation factors; a cognitive-behavioral case conceptual- ization; and common misconceptions about cognitive theory. Where relevant, we use clinical research and case examples to illustrate our conceptual points.
Definition of Anxiety
Anxiety may be defined as a diffuse state (Barlow and Cerney 1988) “characterized by an unpleasant affective experience marked by a significant degree of apprehen- siveness about the potential appearance of future aver- sive or harmful events” (DiTomasso and Gosch 2002, p. 1). The common elements of the anxiety experience include the following descriptions: a tense emotional state characterized by a variety of sympathomimetic symptoms such as chest pain, palpitations, and short- ness of breath; painful uneasiness of mind over an an- ticipated ill; abnormal apprehension; self-doubt as to the nature of a threat; belief about the reality of the threat; and lapses or weaknesses of coping potential. The human nervous system is designed to prepare and mobilize the individual to respond in one of three ways to an objective and physically dangerous threat. We can fight (attack or defend against the force); flee (escape or
avoid); or freeze (become paralyzed). The hallmark of the anxious patient, however, is the presence of a pow- erful perceived threat and the activation of the physical concomitants in the absence of an objective real threat (DiTomasso and Gosch 2002). In other words, the anx- ious person sees threat and reacts accordingly when no real threat exists. As a way of highlighting this point, we differentiate between fear, which we define as a re- sponse to a stimulus that is consensually validated to be scary, and anxiety, a more idiosyncratic response. For example, some individuals can be anxious about flying in an airliner, whereas others may absolutely refuse to fly because of similar concerns. Refusal to fly would be con- sidered an anxiety response, inasmuch as many people do fly with greater or less difficulty. Although some have made this distinction in behavioral terms, others have referred to fear as an unconditioned response and to anxiety as a conditioned response (Barlow 2002).
Basic Assumptions
The cognitive model of anxiety—an information- processing model—makes several basic assumptions about anxiety, its evocation, its mediation, and its sig- nificance (Beck 2005; Beck et al. 1985; Wells 1997). These assumptions are crucial to understanding the phenomenon of anxiety and the nature of anxiety disor- ders from a cognitive perspective.
Beck (2005) proposes that anxiety is a product of bi- ased information processing of stimuli that occur either within or outside the person as threatening, which re- sults in the systematic distortion of the person’s thinking and construction of his or her experiences, as evidenced in thinking errors called cognitive distortions (Yurica and DiTomasso 2005). Underlying these cognitive errors are more lasting dysfunctional beliefs, or cognitive con- tent, contained within cognitive structures known as schemas. More specifically, the cognitive model of anxi- ety “stipulates that danger-oriented beliefs (embedded in cognitive schemas) predispose individuals to narrow their attention to threat, engage in dysfunctional safety behaviors, and make catastrophic interpretations of am- biguous stimuli” (Beck 2005, p. 955). This threat-based bias, seen in each of the disorders of anxiety, is found in all aspects of information processing, including an indi- vidual’s perception of a stimulus, his or her interpreta- tion of it, and even the recall of the stimulus and related information (Beck 2005). The assumptions contained in the cognitive-behavioral model of anxiety are pre- sented below.
1. Fear, an emotional response with adaptive signifi- cance for humans, is evoked in response to objec- tive danger and is a survival mechanism (Beck et al. 1985; Emery and Tracy 1987; Freeman and Simon 1989; Izard and Blumberg 1985; Lindsley 1952, 1957, 1960; Plutchik 1980; Wells 1997).
2. The evocation of anxiety reactions in response to misperceived or exaggerated perceptions of danger when there truly is no danger, or, if there is any dan- ger at all, it is actually quite remote, is by definition maladaptive (Beck and Greenberg 1988; Beck et al. 1985; DiTomasso and Gosch 2002; Foa and Kozak 1986; Freeman and Simon 1989; Wells 1997). 3. Individuals with anxiety disorder are prone to pre-
cipitate false alarms that create a relatively constant state of emotional arousal, tension, and subjective distress. These “fire drills” keep an individual in a relatively constant state of readiness, in which he or she is prepared to confront an anticipated threaten- ing stimulus or situation that never truly material- izes (Barlow and Cerney 1988; Beck and Green- berg 1988; Beck et al. 1985; Freeman and Simon 1989; Wells 1997).
4. The cognitive, physiological, motivational, affec- tive, and behavioral systems are all involved and in- terrelated during anxiety states (Freeman and Si- mon 1989; Persons 1989; Taylor 1988; Wells 1997).
5. The cognitive system plays a primary, vital, and es- sential role in appraising danger and resources and activating the physiological, motivational, affec- tive, and behavioral systems, each of which alone and in concert serve important functions (Beck et al. 1985; Foa and Kozak 1986; Freeman and Si- mon 1989; Lazarus 1991; Wells 1997).
6. The cognitive system mediates its influence through repetitive, unpremeditated, and rapid in- voluntary thoughts and/or images related to threat or danger of which the individual is unaware (un- less attention is called to them), and which the in- dividual accepts as valid without question or chal- lenge (Beck 2005; Beck and Greenberg 1988; Beck et al. 1985; Emery and Tracy 1987; Freeman and Simon 1989; Wells 1997).
7. Automatic thoughts are derived from underlying deeper cognitive structures called schemas, which contain underlying threatening beliefs or assump- tions (Beck 2005; Emery and Tracy 1987; Foa and Kozak 1986; Freeman and Simon 1989; Kendall and Ingram 1987; Persons 1989; Wells 1997).
8. Automatic thoughts and schemas are disorder- specific and, in the case of anxiety, reflect themes of danger and threat, as opposed to the themes of loss typically seen in depressed individuals (Beck 2005; Beck and Rush 1975; Beck and Weishaar 1989; Beck et al. 1985; Foa and Kozak 1986; Freeman and Simon 1989; Hilbert 1984; Wells 1997). 9. Anxiety reactions and disorders may be understood
by elucidating the individual’s automatic thoughts, cognitive distortions, and underlying assumptions (Beck 1976; G. Butler and Matthews 1983; Def- fenbacher et al. 1986; DiTomasso and Gilman 2005; Freeman and Simon 1989; Freeman et al. 1990; Merluzzi and Boltwood 1989; Wells 1997). 10. In anxiety-provoking trigger situations, individu-
als with anxiety disorders tend to activate danger or threat schema, by which they selectively screen-in stimuli and information that indicate danger, and screen-out data that are incompatible with danger or threat (Beck 1976, 2005; Beck et al. 1985; Free- man and Simon 1989; Freeman et al. 1990; Wells 1997).
11. Individuals with anxiety problems have impaired objectivity and ability to evaluate their threat- bound cognitions in a rational and realistic manner (Beck et al. 1985; Wells 1997).
12. Individuals with anxiety disorders show systematic errors in processing information by, for example, overestimating the likelihood of adverse events (Barlow 2002), catastrophizing, selectively ab- stracting, thinking dichotomously, and jumping to arbitrary conclusions (Beck 2005; Beck et al. 1985; Freeman and Simon 1989; Wells 1997).
13. Conceived from Barlow’s triple vulnerability model (Barlow 2002) of the etiology of anxiety dis- orders, an integrated set of three vulnerabilities is relevant to the development of anxiety and related emotional disorders: a) generalized biological vul- nerability, which refers to the genetic contributions to the development of anxiety and negative affect (estimated to account for approximately 30% to 50% of the variance), b) generalized psychological vulnerability, which refers to the development of a lack of a sense of control over salient events in one’s life, based on early life experiences (e.g., early parenting), and c) specific psychological vulnerabil- ity, in which one learns, based on early life experi- ences, to focus anxiety on specific objects or events (e.g., somatic symptoms related to panic or to so- cial evaluation), which in turn become associated
with threat and danger. The synergism of these three vulnerabilities is believed to contribute to the development of anxiety.
More recent cognitive-behavioral treatments share commonalities with traditional CBT but also include very distinctive features. Traditional cognitive-behav- ioral approaches primarily emphasize the importance of altering and restructuring dysfunctional thoughts. As mentioned previously, Acceptance and Commitment Therapy is one of the so-called Third Wave therapies within the cognitive-behavioral realm, with strong roots in behavior therapy and functional contextualism. ACT has gained in popularity and credibility in recent years and stands as an alternative to traditional cognitive ther- apy, which seeks to change distorted cognitions and re- lated affect, as well as to more purely behaviorally based approaches that seek to alter contingencies that rein- force avoidance behaviors. ACT is grounded in Rela- tional Frame Theory and considers symbolic language to be the primary source of painful affect because of its use of experiential avoidance and cognitive fusion (Hayes and Pierson 2005).
In treating anxiety disorders with ACT, the therapist focuses on refraining from evaluation through the use of defusion and distancing techniques, while teaching methods for refocusing on the experience in the here and now. In ACT, patients with anxiety are taught to observe their thoughts and images as inner language as they sep- arate the words of private dialogue from the actual expe- rience of threat. Patients are taught to accept negative and painful experiences as paradoxically vital compo- nents of living a full life, rather than continue trying to restrict their experience through the use of escape and avoidance in order to reassure themselves of relief from suffering. Techniques typically used in ACT include meditation and mindfulness, paradoxical acceptance, and nonjudgmental cognitive defusion. In the final phases of ACT, patients are taught to reassess their val- ues about meaning-making in life. They are asked to commit to living life on life’s terms in the present and not trying to control experience by anticipating potential threats to safety and potential ways to avoid them.
Mindfulness-Based Cognitive Therapy (Baer 2003) is based on the work of John Cabot-Zinn. In this type of therapy, patients are taught to identify and accept feel- ings and thoughts on a transitory basis, to increase their awareness, and to decide to respond instead of reacting automatically to thoughts, feelings, and situations. MBCT assists patients in overcoming the habitual ten-
dency to react automatically. Specifically, mindfulness- based interventions have been found to improve symp- toms related to generalized anxiety and panic, among other problems (Baer 2003).
Critical to the general cognitive-behavioral model is the cognitive appraisal of the individual about stressor events. This model of anxiety also makes explicit as- sumptions about the predisposing and precipitating fac- tors that are associated with the onset of anxiety disor- ders. In the sections that follow, we discuss several predisposing and precipitating variables related to anx- iety disorders. It is important to bear in mind that any combination of these factors may set the stage and pro- vide the impetus for the development, onset, mainte- nance, and exacerbation of anxiety problems.