Basic CBT Models of Anxiety Disorders

A JAY K U MA R P H D
A S S I STA NT P R O FESSOR O F C L I N I C A L P S YCHOLOGY,
C O NS ULTA NT I N T H E B E H AVI ORA L M E D I C I N E U N I T,
N I MH A N S, A JAYCOG2 01 0 @GMA I L.COM
 Anxiety disorders: Introduction and Overview

The most prevalent psychiatric syndromes (17 percent)

Intense, unrealistic anxiety, exaggerated and/or unrealistic cognitions
about future threat of harm
Physiological responses when confronted with anxiety-relevant stimuli
Behavioral tendencies to escape from or avoid anxiety triggers and to
prevent anticipated harm.
 Central tenets of the cognitive model of anxiety
1. Automatic and strategic cognitive processing are responsible for the
involuntary & uncontrollable quality of anxiety.

2. Anxiety is a state of heightened vulnerability

Exaggerated threat appraisals: An enhanced & highly selective

attention to personal risk, threat that is perceived as having a serious
negative impact on vital interests and well-being.

Heightened helplessness: An inaccurate evaluation of personal coping

resources.
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3. Impaired constructive or reflective thinking: Difficult to access and so
are ineffectively utilized for anxiety reduction.

4. Inhibitory processing of safety information: Safety cues/information

that convey diminished likelihood/ severity of a perceived threat.

5. Anxiety have self-perpetuating process: “anxious about being

anxious.”

6. Cognitive primacy: Appraisals can generalized threat to broader array

of situations & various physiological/behavioral defensive responses
are inappropriately mobilized to deal with the threat.

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 Maintaining factors in anxiety disorders

Safety seeking behaviours

Attention deployment: Towards/away from threat

Spontaneously occurring images

Emotional reasoning

Memory processes (retrieval of confirmatory information)

 Introduction-Anxiety models

No single theory or model of anxiety

Beck and allied approaches most widely applicable

Basic premise – experience of emotional disturbance due to interpretation

of events

Behavioural & cognitive responses - serve to maintain anxiety

 Overprotective parents, anxious parenting,
uncertain health

Danger schemas : I must be careful of my health, My health is

uncertain, I am weak & vulnerable, cannot cope…

Sudden change in
health, death of close relative

If I am not careful..then I am in great danger

What if I fall sick? I am weak, I cannot be alone

Anxiety symptoms, behavioral responses,

cognitive biases- safety behaviors, avoidance that maintain
anxiety and beliefs of vulnerability
 Emotional processing theory

Cognitive fear structure: Representations of stimulus, response & meaning

Environmental stimuli activate spreading of activation throughout

the rest of the structure via associative connections.

If the stimuli represented in it are objectively harmful & the responses

represented in it lead to effectively avoiding, escaping, or coping with the
threat (Adaptive cognitive fear structure).

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 Pathological Cognitive fear structure
Associations among stimulus (dogs), response (physiological arousal &
various defensive behaviors) and meaning (dangerous/ uncontrollable).
When representations do not accurately reflect reality such that harmless
stimuli or responses are erroneously interpreted as being dangerous.

The fear structure in PD is characterized by fear of physical sensations

associated with panic symptoms (heart palpitations) and interpretation of
these sensations as indications of danger (heart attack).

As a result of the erroneous meaning associated with these sensations,

people with panic disorder avoid situations that they anticipate to give rise
to panic, such as intense physical activity.
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 Emotional Processing
Changes in a pathological element of a fear structure anxiety reduction
1. The fear structure must be activated
2. New information that is incompatible must be available & incorporated
into the structure, thereby altering the structure and creating a more
realistic structure via competing associations.

Indication for change in the structure:

A. Reduction in the levels of distress across repeated sessions
B. Reductions in fear-related cognitions
C. Gradual reduction in these indexes of emotional reactivity

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 Failures of emotional processing
Prolonged and uninterrupted emotional engagement essential for
emotional processing

Escape/avoidance strategies (Negative reinforcement)

Distraction and use of Benzodiazepine medications

Safety behavior
Example: Fears of dying from a panic attack, activating the fear structure,
but then immediately sits down & drinks hot water to prevent dying, he will
not learn that the panic attack is not dangerous.

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 Cognitive behavioral model of panic disorder

Anxiety Sensitivity

Catastrophic interpretation of benign interoceptive cue: “I am going crazy”

(or heart attack) leading to hypervigilance for signs of anxious arousal.

Safety behaviors (being accompanied by another person, stiffening one's

posture, taking deep breath etc.).

Avoidance/escape: Situations that trigger increased arousal are anticipated

with dread and avoided/escaped.

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Cognitive behavioral model of social
anxiety disorder

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 Hallmark symptom of SAD is “Fear of Negative Evaluation”

SAD Maintained by Dysfunctional thinking/biased information processing

Danger of revealing anxiety symptoms or behaving ineptly will have

disastrous consequences (loss of status, worth & rejection).

Perfectionistic standards of performance, an excessive need for approval,

beliefs of incompetence or undesirability & others are inherently critical.

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 Maladaptive social self-schemas
Schema content Examples
Inferior social self “I’m boring”

Beliefs about others “People are critical of others”

Beliefs about disapproval “It is awful when others disapprove of you”

Beliefs about social performance “I must always sound intelligent & interesting
standards to others”

Beliefs about anxiety and its effects Anxiety is a sign of emotional weakness & loss
of control”

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 Dysfunctional beliefs are perpetuated by
Disregard positive feedback, avoid social situations altogether, use safety-
seeking behaviors to reduce their anxiety.

Self as a Negative Social Object leads to poorer social performance &

increases the likelihood of negative appraisals by observers.

1. Feelings of embarrassment/shame are often the dominant emotions

2. Intense anxiety elicits automatic inhibitory behaviors & attempts to
conceal anxiety disrupting social performance
3. Anxiety itself becomes a secondary threat
 Cognitive model for GAD
Chronic & excessive worry
Worry as a self-perpetuating maladaptive cognitive avoidance strategy that
contributes to the persistence of anxiety by:
1. Magnifying a biased interpretation of anticipated threat.

2. Generating a false sense of control, predictability & certainty.

3. Erroneous attribution of the nonoccurrence of the dreaded outcome

to the worry process.

4. Culminating in frustrative attempts to establish a sense of safety.

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 Category of beliefs in GAD
Schema categories Examples
General threat If I experience a negative event, it will have a serious
effect on me.
Personal vulnerability I would be unable to cope with the negative event if it
occurred.
Intolerance of uncertainty It is important to be ready for any unexpected bad things
that could happen to you.

Metacognition of worry Worry helps me solve problems & prepare for the worst.

I experience a great deal of distress because of

uncontrollable worry.
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 Metacognitive model

Worrying means I’ll be prepared Worrying is uncontrollable

If I worry I won’t be taken by
surprise
If I worry I’ll be able to cope
Worrying will damage my body
and cause a heart attack
If I worry I could become
schizophrenic or lose my mind
When people discover I worry
they will reject me
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 The Cognitive Model for Depression

People’s emotions, behaviors, and physiology are

influenced by their perception of events.

Situation/event

Automatic thoughts

Reaction (emotional, behavioral, physiological)

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 Cognitive Conceptualization Diagram
RELEVANT CHILDHOOD DATA

CORE BELIEFS

CONDITIONAL ASSUMPTIONS/ BELIEFS/ RULES

COPING STRATEGIES

SITUATION #1 SITUATION #2 SITUATION #3

AUTOMATIC THOUGHT AUTOMATIC THOUGHT AUTOMATIC THOUGHT

MEANING OF AT MEANING OF AT MEANING OF AT

Emotion Emotion Emotion

Behavior Behavior Behavior

© 2011, Beck, J.S. Cognitive Behavior Therapy: Basics and Beyond (2nd ed.). www.beckinstitute.org.
Specific cognitive errors in anxiety disorders

Catastrophizing

Selective abstraction

Mind reading

Fortune telling

Emotional reasoning

Over generalizing

Personalization
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