David J. Walczyk, Ed.D.C.G. Jung Institute of NY

Cognitive (Behavioral) Therapy of Anxiety Disorders

As they relate to the cognitive therapy of anxiety disorders...

Cognitive ModelGeneral Hypotheses

EtiologyCognitive InterventionCase Formulation : GAD

Cognitive ModelGeneral Hypotheses

EtiologyCognitive InterventionCase Formulation : GAD

“Modification of the exaggerated appraisals of threat, vulnerability, and safety seeking is the primary

objective of cognitive therapy for anxiety disorders.”

“The goal of any cognitive intervention is deactivation of the hypervalent threat schemas and heightened

activation of more adaptive and realistic beliefs about threat and perceived ability to cope with one’s anxious

concerns.”

Cognitive ModelGeneral Hypotheses

EtiologyCognitive InterventionCase Formulation : GAD

1. Attentional threat biasSelective attentional bias for negative stimuli

2. Diminished attentional processing of safetyAutomatic attentional shift away from safety cues

3. Exaggerated threat appraisalsAutomatic evaluative process that exaggerates the threat

4. Threat-biased cognitive errorsCommit more cognitive errors while processing threatening stimuli

5. Negative interpretation of anxietyGenerate more negative and threatening interpretations

of subjective feelings and symptoms

6. Elevated disorder-specific threat cognitionElevated frequency, intensity, and duration of

negative automatic thoughts and images

7. Ineffective defensive strategiesLess effective immediate defense strategies and

evaluate defensive strategies as less effective

8. Facilitated threat elaborationSelective bias threat even towards ambiguous stimuli

9. Inhibited safety elaborationInhibitory bias of safety information relevant to

selective themes - fewer themes of safety

10. Detrimental cognitive compensatory strategies

E.g... worry has a greater adverse effect to enhancing threat salience

11. Elevated personal vulnerabilityLower-self confidence and greater perceived helplessness

in situations relevant to their selective threats

12. Enduring threat-related beliefsPreexisting maladaptive schemas about particular threats

or dangers and associated personal vulnerability

Cognitive ModelGeneral Hypotheses

EtiologyCognitive InterventionCase Formulation : GAD

“...vulnerability to anxiety disorders involves the interaction of multiple pathways emerging from constitutional, developmental, environmental,

personality, and information-processing domains.”

“Based on this framework for vulnerability, we...consider the empirical evidence for the two main

components of the model: an enduring sense of personal vulnerability and the presence of hypervalent threat

schemas.”

Cognitive ModelGeneral Hypotheses

EtiologyCognitive InterventionCase Formulation : GAD

“Cognitive interventions seek to shift the clients perspective from one of exaggerated danger and

personal vulnerability to a perspective of minimal acceptable threat and perceived ability to cope.”

What...

Shift threat focusTend to enter therapy believing that the cause of their anxiousness

is the situation that triggers their anxious episode

Focus on appraisals and beliefsAn information-processing system that exaggerates the probability and severity

of threat, minimizes personal ability to cope, and fails to recognize aspects of safety.

Modify biased threat, vulnerability, and safety appraisals and beliefs

Four key elements of faulty cognition : probability estimates, severity estimates, vulnerability estimates, and safety estimates

Normalize fear and anxietyNormalize in relation to others, normalize in relation to past experiences,

and normalize in relation to situations.

Strengthen personal efficacyCorrecting erroneous beliefs about personal vulnerability and

perceived inability to deal with anxious concerns.

Adaptive approach to safetyFaculty risk appraisal, enhance safety-seeking processing,

dysfunctional avoidance and safety-seeking behavior

How...

Educating the clientDefine anxiety and fear, explain consequences, treatment goal, treatment strategy

Self-monitoring and the identification of anxious thoughts

Identify and record anxious behavior

Cognitive restructuringEvidence gathering, cost-benefit analysis, decatastrophizing, identifying

cognitive errors, generating alternatives, empirical hypothesis testing

Identifying thinking errorsTo reinforce the message to clients that threat perception are inaccurate

Generate and alternative explanationFrom rigidity to reflection

Empirical hypothesis-testingDevelopment and test hypothesis

Emerging Hows...

Imaginal reprocessing and expressive writing*

Mindfulness, acceptance, and commitment*

Cognitive ModelGeneral Hypotheses

EtiologyCognitive InterventionCase Formulation : GAD

Primary goal of cognitive therapy of GAD...

“...reduction in frequency, intensity, and duration of worry episodes that would lead to an associated decrease in automatic anxious intrusive thoughts and generalized anxiety. This will be achieved by modifying the dysfunctional

appraisals and beliefs as well as the maladapative control strategies that are responsible for chronic worry.”

Case Formulation in conjunction with client...

1. Description of the primary worry concerns

2. Specification of current life goals and personal strivings

3. List of internal and external triggers of worry

4. Identification of metacognitive appraisals of worry of each worry concern

5 Description of idiosyncratic worry control profile

6. Extent of safety and search and negative problem orientation

7. Formulation of the underlying schematic organization responsible for chronic worry and generalized anxiety.

Case Formulation in conjunction with client...

1. Focus on identifying the dysfunctional schemas and faulty metacognitive processes of worry.

2. Assess the client’s primary worried and associated anxious symptoms (use ADIS-IV to assess context of worry, presence of safety-seeking responses, and

degree of interference in daily life).

3. Identify client’s personal goals and current concerns.

4. Identify worry triggers (using the Worry Self-Monitoring Form B)

5. Identify client’s metacognitive appraisals of worry

6. Identify Worry Control Strategies using the Cognitive Response to Anxiety Checklist

7. Develop safety scripts and problem orientation

8. Identify core maladaptive schemas of threat, personal vulnerability, intolerance of uncertainty, and metacognitive beliefs about worry

Primary source...

Cognitive Therapy of Anxiety DisordersScience and Practice

David A. Clark and Aaron T. Beck(2011)

Thanks!