Cognitive Behavioral Therapy for Anxiety

Are you living with anxiety? Do you know someone who always views the glass half empty? Given recent events such as natural disasters, shootings, bombings and the recession, it’s not surprising that many of our friends, family members and our patients have experienced various levels of anxiety. An individual doesn’t have to be directly affected by an adverse event to feel anxious. An Anxiety disorder crosses all races and socioeconomic classes and can even affect our support systems such as healthcare professionals, police officers, fire fighters and first responders. In a given year, approximately 18.1 percent of Americans are diagnosed with an anxiety disorder (Kessler, Chiu, Demler, & Walters, 2005). The symptoms denoting an anxiety disorder may be divided into cognitive, affective, behavioral, and physiological.

Cognitive symptoms can include hypervigilence, inability to recall important things, confusion, distractibility, loss of objectivity, cognitive distortion, or repetitive fearful ideation. Individuals with affective symptoms can exhibit impatience, tension, feeling frightened or alarmed. Behavioral symptoms can be illustrated by inhibition, tonic immobility, speech dysfluency, impaired coordination, restlessness, or hyperventilation. Physiological symptoms can present as palpitations, heart racing, increased blood pressure, pressure on the chest, rapid breathing, startle reaction, insomnia, tremors, loss of appetite, abdominal discomfort, nausea, flushed face, or sweating (Beck, Emery, & Greenberg, 1985).

Metaphorically, an anxiety disorder can be conceptualized as a hypersensitive alarm system. The anxious individual is highly sensitive to stimuli and is vigilant about potential or perceived dangers. This individual experiences innumerable false alarms which keep him or her in a constant state of emotional stress and turmoil. This preoccupation with danger is manifested by the involuntary intrusion of automatic thoughts whose content involves possible physical or mental harm.

Automatic thoughts consist of interpretations of events or experiences that are spontaneous, appear valid, and associated with problematic behavior or disturbing emotions. These thoughts occur in shorthand and are often composed of one word or a short phrase which can function as a label for a group of painful memories or fears. Automatic thoughts are spontaneous thus the individual believes the automatic thought because of its reflexive nature. These thoughts are often unconscious, persistent and self-perpetuating as automatic thoughts are hard to turn off or change because they are ingrained into an individual’s thinking. Automatic thoughts are relatively idiosyncratic, unique to the individual’s view of the stimulus event, and generally involve a distortion of reality that is repetitive. Subsequently, the result is an intense emotional response to the underlying distorted thought (Beck, 1976).

Automatic thoughts are almost always believed no matter how illogical the thought appears. These thoughts occur despite the fact that they are contrary to objective and reasonable evidence. Automatic thoughts have the same believable quality as direct sense impressions thus the anxious individual attaches the same truth to automatic thoughts as to sights and sounds of the real world without question. Unfortunately, this individual continues to have automatic thoughts no matter how many times these thoughts are invalidated by external experience or solid evidence. These thoughts tend to occur repetitively and rapidly and seem completely plausible at the time of their occurrence. Many times, a thought is so fleeting that the individual is aware only of the anxiety it has generated. While the individual may agree that these fearful thoughts are illogical, his or her ability to view them objectively without help is limited. The individual behaves as though he or she believes in the validity of one’s misinterpretations (Beck, Emery, & Greenberg, 1985).

A common misinterpretation or faulty thinking which is characteristic of many anxious patients is catastrophizing. Individuals who catastrophize tend to dwell on the worst possible outcome of any situation in which there is a possibility for an unpleasant outcome. The individual overemphasizes the probability of a catastrophic outcome or exaggerates the possible consequences of its occurrence. The anxious individual has no patience for uncertainty or ambiguity and views possible dangers in absolute, extreme terms which only increases anxiety as one approaches the danger situation. This anxiety can be manifested in numerous ways such as sweating, difficulty breathing, hands trembling, heart racing and wobbliness in legs.

To alleviate the anxiety the individual can be trained to rewind and recover the automatic thought preceding the affect. Subsequently, according to Beck’s cognitive behavioral theory, anxiety should improve as these thoughts are unlearned and changed (Beck, Emery, & Greenberg, 1985).

Cognitive Behavioral Theory

Cognitive Therapy has been supported in the research to be effective in treating anxiety and negative automatic thoughts (Kehle, 2008; Stanley et al., 2009). Cognitive therapy is an active, directive, time limited structured approach used to treat depression and anxiety. Cognitive Therapy is based on an underlying theoretical rationale that an individual’s affect and behavior are largely determined by the way in which he or she structures the world (Beck, 1967). The individual’s cognitions are based on attitudes or assumptions (schemas), developed from previous experiences (Beck, Rush, Shaw, & Emery, 1979).

The therapeutic techniques are designed to identify, reality test, and correct distorted conceptualizations as well as the dysfunctional beliefs (schemas) underlying these cognitions. The individual learns to master problems and situations which he or she previously considered impossible by re-evaluating and correcting his or her thinking. The cognitive therapist assists the individual to both think and act more realistically and adaptively about his or her psychological problems and thus reduce symptoms (Beck, Rush, Shaw, & Emery, 1979).

A variety of cognitive and behavioral strategies are utilized in cognitive therapy. Cognitive techniques are aimed at delineating and testing the individual’s specific misconceptions and maladaptive assumptions. This approach consists of highly specific learning experiences designed to teach the individual the following operations: (1) to monitor negative, automatic thoughts (cognitions); (2) to recognize the connections between cognition, affect, and behavior; (3) to examine the evidence for and against distorted thoughts; (4) to substitute more reality-orientated interpretations for these biased cognitions; and (5) to learn to identify and alter the dysfunctional beliefs which predispose him or her to distort experiences (Beck, Rush, Shaw, & Emery, 1979).

Various verbal techniques are used to explore the logic behind and basis for specific cognitions and assumptions. The individual is initially given an explanation of the rationale of cognitive therapy. Next, he or she learns to recognize, monitor, and record one’s negative thoughts on the Daily Record of Dysfunctional Thoughts. The cognitions and underlying assumptions are discussed and examined for logic, validity, adaptiveness, and enhancement of positive behavior versus maintenance of pathology (Beck, Rush, Shaw, & Emery, 1979). Behavioral techniques are used with more severely anxious individuals not only to change behavior, but also to elicit cognitions associated with specific behaviors. A sampling of these behavioral strategies include a Weekly Activity Schedule in which the individual logs his or her hourly activities; a Mastery and Pleasure Schedule, in which the individual rates the activities listed in his or her log; and Graded Task Assignments in which the individual undertakes a sequence of tasks to reach a goal which he or she considers difficult or impossible. Furthermore, behavioral assignments are designed to help the individual test certain maladaptive cognitions and assumptions (Beck, Rush, Shaw, & Emery, 1979).

Therapy generally consists of 15-25 sessions at weekly intervals. The moderately to severely anxious individual usually requires therapy on a twice-weekly basis for at least 4 to 5 weeks and then weekly for 10-15 weeks. The frequency of therapy is tapered to once every 2 weeks for the last few visits and booster therapy is recommended after the completion of the regular course of treatment. These follow up visits may be scheduled on a regular basis or may be left to the discretion of the individual (Beck, Rush, Shaw, & Emery, 1979).

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