Read feedback from a recent workshop participant. She implemented techniques she learned during a roleplay with Dr. Aaron Beck.
Norman Cotterell, Ph.D.
Beck Institute for Cognitive Behavior Therapy
Beck and Gellatly (2016) propose that catastrophic thinking is a central feature in psychopathology. Such thinking magnifies both the immediate and eventual consequences of any perceived threat. A variety of disorders can be conceptualized as such: Clients magnify external threats (accidents, attacks, arson) but most notably misinterpret and magnify perceived internal threats. Sensations, thoughts, and emotions are seen as signs of immediate physical or psychological catastrophe.
- Panic — immediate catastrophic consequences of an unexpected physical sensation: “If my heart races, I’m dying.” “If I feel lightheaded, I’m about to faint.”
- Social Phobia — catastrophic misinterpretations of the social consequences of anxiety: “If people see me sweat, I’ll be judged, shunned, rejected or shamed.”
- Agoraphobia — catastrophic beliefs about the consequences of anxiety: “If I panic, I’ll be trapped.”
- Specific phobias — catastrophic beliefs about a feared object or situation: “If I get on an airplane, I won’t be able to handle the anxiety.”
- Health anxiety — catastrophic consequences of an unexpected physical sensation, or image: “If my chest hurts, I have heart, lung, or infectious disease. If the doctor sends me for tests, it means I’m seriously ill.”
- Obsessive compulsive disorder — Catastrophic misinterpretation of an intrusive thought: “If I think something unacceptable, it means I myself am unacceptable. Thinking it is as bad as doing it.”
- Posttraumatic Stress Disorder — Catastrophic beliefs about the reoccurrence of danger: “If it happened before, it’s likely to happen to me again.” “Flashbacks mean danger.”
- Pain — Catastrophic beliefs about pain and its consequences: “If I’m in pain, it is unsafe to move, and I must stop my activities.”
- Traumatic Brain injury — Catastrophic misinterpretations of post concussive symptoms: “If I have a headache, my brain injury is getting worse.”
Beck and Gellatly regard such thinking as an essential ingredient in the development and maintenance of these anxiety disorders. They identify 6 essential ingredients of a cycle that fuels them: Catastrophic Beliefs (“I’m having a heart attack, I’m dying,”) triggered by a Precipitating Event (heart palpitations) results in both Anxiety Symptoms (shortness of breath, dizziness, feeling out of control) and an Interpretive Bias (“If my chest hurts, I’m having a heart attack”). These, in turn trigger an Attentional Fixation (“There’s no other way to look at this!”) and an Attentional Bias (“I really need to pay close attention to my chest.”) And these attentional factors serve to refuel the anxiety, the interpretative bias, the catastrophic beliefs and each other.
Beck and Gellatly propose taking catastrophizing into account would be useful in the diagnosis, prediction, prevention, and treatment of psychopathology. Future research and exploration will answer such questions as: Which catastrophic beliefs differentiate which conditions? Who is susceptible to developing such beliefs? How do we educate people to promote resiliency against such beliefs? What interventions will best enable clients to counter these beliefs?
Although they point to catastrophic beliefs as the key essential factor, other factors may serve as points of interventions. Decatastrophizing enables clients to test the validity of catastrophic beliefs through exposure to the sensations. Therapists use panic inductions, for example, to alter the misinterpretation of symptoms. Other techniques, such as cognitive reappraisal, may ameliorate attentional fixation by providing more plausible ways to account for symptoms. Various in-office procedures may modify attentional bias by directing focus to breathing, to objects in the office, or to sounds inside and outside the building. This model may serve as a way to conceptualize the problem and identify where interventions work.
Beck, A.T. & Gellatly, R. Catastrophic Thinking: A Transdiagnostic Process Across Psychiatric Disorders. Cognitive Therapy and Research, 2016, pp. 1-12.
Judith S. Beck, Ph.D. and Robert Hindman, Ph.D.
At our recent Core 2 CBT for Anxiety Disorders workshop, we asked participants what is helpful in managing anxiety? What is not helpful?
Individuals with anxiety disorders unwittingly maintain their conditions by their behavioral strategies and their beliefs.
Avoidance is a hallmark of anxiety. Sometimes the avoidance is blatant, when, for example, an agoraphobic client does not leave the house. But sometimes it is quite subtle. For example, one of our panic patients tightly gripped the steering wheel while driving. A client with obsessive compulsive disorder tries not to think about an idea which is unacceptable to her. One of our most recent clients with social anxiety avoids making eye contact and tries to control his shaking hands.
Worrying is also unhelpful for people with anxiety disorders. Sometimes clients believe that it is important for them to worry in order to prevent danger; however, worrying actually leads to their continually overestimating danger over time. Our anxious clients have beliefs such as, “The world is dangerous.” “I have to be on guard. I need to anticipate any problems that could possibly arise; otherwise I’d be irresponsible.” “If I worry, I can figure out exactly what I should do.” Then, when the predicted catastrophe doesn’t happen, instead of recognizing that it was not likely to occur, they tell themselves, “It was good that I worried about it or else it might have happened.”
Anxious clients also demand certainty. A client we saw this week told me, “I have to know for sure that nothing bad will happen.” But many outcomes in life are unpredictable, or can’t be predicted with absolute certainty. Assuming that certainty is possible and demanding that they obtain certainty keeps anxiety going. One dysfunctional strategy clients use to demand certainty is constant reassurance seeking. For example, a client frequently seeks reassurance from her husband that he still loves her and will never leave. Demanding certainty is also associated with her attempts to over-control herself, her husband and children, and even her co-workers. For instance, she’s constantly texting her husband and children to make certain they’re ok, and will keep on frantically texting them until she hears back.
Another habit anxious clients have is paying too much attention to their anxious thoughts. People without anxiety disorders often do an automatic reality check and/or engage in problem solving when they notice anxious thoughts. Or they dismiss them as “just thoughts” and refocus their attention back to the task at hand. When an anxiety disorder is present, though, clients focus on their anxious thoughts, treat them as “facts;” their anxiety increases, and they often engage in an unhelpful action (such as the thought suppression, worry, or reassurance seeking mentioned above).
Perfectionism is also sometimes involved in maintaining anxiety disorders. Another recent client of ours believed, “I should be perfect because if I’m not, I’m vulnerable to bad things happening. I should figure out the perfect solution to any problem. If things aren’t perfect, everything will fall apart.” The problem with perfectionism is that it’s impossible to be perfect. When our client doesn’t meet her perfect expectations, she doesn’t think it’s because her standards are unrealistic, but instead, takes it as more evidence that she’s vulnerable to bad things happening, which keeps her anxiety elevated over time.
Finally, clients with anxiety disorders have difficulty tolerating, much less accepting the experience of anxiety because they are “anxious about being anxious”. One client we mentioned above believed that anxiety was bad and that if she didn’t try to control it, it would get worse and worse until she just couldn’t stand it and would “lose control.” You can think of anxiety as energy for a challenge, so when you believe experiencing anxiety is a challenge, you end up getting an additional level of anxiety whenever it shows up.
Fortunately, a large body of literature now supports the efficacy of Cognitive Behavior Therapy in effectively treating anxiety disorders. And treatment has become even more effective in recent years as therapists have added mindfulness to their repertoire of techniques, helping clients label and accept the experience of anxiety and learning, not how to try to rid themselves of it, but how to move anxiety to the background as they focus on whatever valued activity they are engaged in at the moment.
By Judith S. Beck, Ph.D., and Francine R. Broder, Psy.D.
We’ve stopped using the word “homework” in CBT. Too many clients take exception to that term. It reminds them of the drudgery of assignments they had to do at home when they were at school. So in recent times, we’ve switched. “Homework” is now called the “Action Plan.”
We like the label “Action Plan.” It conveys a sense of proactivity, of taking control.
Action plans aren’t optional. They are very carefully created, in a collaborative fashion. Therapists emphasize that most of the work in getting better happens between sessions. A significant part of each session involves helping clients figure out what they need to do outside of the therapy office to feel better and regain a good level of functioning. We tell clients:
That’s why we make sure that whatever is important for the client to remember about the session, including their Action Plan, is recorded, written down or entered as text or audio into an electronic device.
How likely are you to do this assignment(s) this week?
And that’s why we continue talking about potential obstacles that could get in the way when clients say they are 90% or less likely to complete the Action Plan.
Here is an example of a client who did not do his action plan, and this is how we worked on it.
A 28-year-old came to treatment to work on reducing depression, social anxiety, and worry about his irritable bowel syndrome. During our session, he identified “getting into shape” as important to him and set up a specific action plan that included going to the gym he belonged to, two times during the week, for approximately 30 minutes. Upon returning the following week and checking in on how it went, he stated he did not go. When asked what got in his way, he stated he did not know. He was asked to go back to an earlier time in the week, imagine himself about to go to the gym, and to notice the thoughts that were going through his mind. Using imagery, he was able to identify his interfering thoughts. Next, we used Socratic questioning, summarizing his conclusions in a two-column thought record.
The Action Plan isn’t optional. A considerable body of evidence shows that clients who do homework have better outcomes than clients who do not. See, for example Conklin & Strunk (2015); Kazantzis, Deane, Ronan & L’Abate (2005). It’s up to therapists to help clients carefully design meaningful assignments with a good likelihood of success and to motivate clients to follow through. Finally, we used the two-column thought record to anticipate additional interfering thoughts that could get in the way of engaging in his action plan for the coming week.
Conklin, L. R., & Strunk, D. R. (January 01, 2015). A session-to-session examination of homework engagement in cognitive therapy for depression: Do patients experience immediate benefits?. Behaviour Research and Therapy, 72, 56-62.
Kazantzis, N., & L’Abate, L. (2006). Handbook of homework assignments in psychotherapy: Research, practice, and prevention. New York, NY: Springer.
Introduction: The future of psychotherapy relies on the dialog with the basic science, being the identification of psychotherapeutifc biomarkers of efficacy a core necessity. Heart rate (HR) is one of the most studied psychophysiological parameters in anxiety disorders.
Methods: To investigate the impact of cognitive behavior therapy (CBT) on the HR of patients with anxiety disorders, we conducted a meta-analysis and systematic review. Electronic searches were conducted in the ISI/Web of Knowledge, PsychINFO and PubMed/MEDLINE for studies which evaluated HR at least once before and after CBT. Keywords related to anxiety disorders, HR and CBT were used in the search.
Results: 474 studies, of which 47 were selected for the systematic review and 8 for the meta-analysis, were identified. The results provide evidence that CBT significantly decreases the HR of posttraumatic stress disorder patients. In social phobia, obsessive–compulsive disorder and acute stress disorder, the results point in the same direction, although it is still early to attribute the decrease in HR to CBT. In specific phobias, traditional exposure therapy showed greater effect size than exposure with distractors or without psycho-education.
Limitations: Most of the randomized trials have not been conducted in accordance with rigorous methodological quality criteria. Conclusions: Standardization in the methods used and in treatment protocols, as well as investigations in groups of patients with low physiological reactivity, are necessary in order to reach better conclusions. Notwithstanding these limitations, HR is beginning to emerge as a potential biomarker of efficacy in anxiety disorders.
Gonçalves, R., Rodrigues, H., Novaes, F., Arbol, J., Volchan, E., Coutinho, E. S. F., . . . Ventura, P. (2015). Listening to the heart: A meta-analysis of cognitive behavior therapy impact on the heart rate of patients with anxiety disorders. Journal of Affective Disorders, 172, 231-240.
We examined whether Cognitive-Behavioral Therapy (CBT) for social anxiety disorder (SAD) would modify self-reported negative emotion and functional magnetic resonance imaging brain responses when reacting to and reappraising social evaluation, and tested whether changes would predict treatment outcome in 59 patients with SAD who completed CBT or waitlist groups. For reactivity, compared to waitlist, CBT resulted in (a) increased brain responses in right superior frontal gyrus (SFG), inferior parietal lobule (IPL), and middle occipital gyrus (MOG) when reacting to social praise, and (b) increases in right SFG and IPL and decreases in left posterior superior temporal gyrus (pSTG) when reacting to social criticism. For reappraisal, compared to waitlist, CBT resulted in greater (c) reductions in self-reported negative emotion, and (d) increases in brain responses in right SFG and MOG, and decreases in left pSTG. A linear regression found that after controlling for CBT-induced changes in reactivity and reappraisal negative emotion ratings and brain changes in reactivity to praise and criticism, reappraisal of criticism brain response changes predicted 24% of the unique variance in CBT-related reductions in social anxiety. Thus, one mechanism underlying CBT for SAD may be changes in reappraisal-related brain responses to social criticism.
Goldin, P. R., Ziv, M., Jazaieri, H., Weeks, J., Heimberg, R. G., & Gross, J. J. (2014). Impact of cognitive-behavioral therapy for social anxiety disorder on the neural bases of emotional reactivity to and regulation of social evaluation. Behaviour Research and Therapy, 62, 97-106.
OBJECTIVE: A few meta-analyses have examined psychological treatments for a social anxiety disorder (SAD). This is the first meta-analysis that examines the effects of cognitive behavioural group therapies (CBGT) for SAD compared to control on symptoms of anxiety.
METHOD: After a systematic literature search in PubMed, Cochrane, PsychINFO and Embase was conducted; eleven studies were identified that met the inclusion criteria. The studies had to be randomized controlled studies in which individuals with a diagnosed SAD were treated with cognitive-behavioural group therapy (CBGT) and compared with a control group. The overall quality of the studies was moderate.
RESULTS: The pooled effect size indicated that the difference between intervention and control conditions was 0.53 (96% CI: 0.33-0.73), in favour of the intervention. This corresponds to a NNT 3.24. Heterogeneity was low to moderately high in all analyses. There was some indication of publication bias.
CONCLUSIONS: It was found that psychological group-treatments CBGT are more effective than control conditions in patients with SAD. Since heterogeneity between studies was high, more research comparing group psychotherapies for SAD to control is needed.
Wersebe, H., Sijbrandij, M., & Cuijpers, P. (January 01, 2013). Psychological group-treatments of social anxiety disorder: a meta-analysis. Plos One, 8, 11.)
A recent study published in the Journal of Research in Childhood Education, investigated the effect of using Cognitive Behavior Therapy (CBT) in a social setting on children’s anxiety levels. Typically, children with anxiety have the most difficulty with evaluating and managing emotions, which may lead to poor peer relationships and maladaptive coping strategies. Because anxiety disorders are the most common mental health conditions in children, research on early intervention is warranted. Emotional Management Training (EMT) is a form of CBT that helps children learn to regulate anxious emotions. Participants in the current study were primarily recruited from a New York City mental health clinic and included 58 children, ages 5-14, diagnosed with anxiety disorders. The program included social and therapeutic group activities, as well as CBT skills to help children manage anxious emotions. Specifically, the EMT CBT intervention consisted of psychoeducation about emotional and physical anxiety symptoms, relaxation and meditation therapy, cognitive restructuring, and exposure activities. Results demonstrated overall improvement in anxiety symptoms measured by the Multidimensional Anxiety Scale for Children, program satisfaction surveys, self-reports, and therapist and parent reports. These findings suggest that EMT may be a helpful alternative for anxious children in social settings.
Kearny, R., Pawlukewicz, J., & Guardino, M. (2014). Children with anxiety disorders: Use of a cognitive behavioral therapy model within a social milieu. Journal of Research in Childhood Education, 28, 59-68. doi: 10.1080/02568543.2013.850130
According to a recent study published in Plos One, cognitive behavior therapy (CBT) may help reduce experiences of shame (specifically associated with how individuals judge themselves) among patients diagnosed with social anxiety disorder (SAD.) Participants (n= 161) in the current study were initially evaluated for experiences of shame, guilt, depression, and social anxiety. Participants diagnosed with SAD (n=67) were assigned to a CBT treatment condition; the remaining participants (n=94) were assigned to two samples of healthy controls. According to results, shame, social anxiety, and depressive symptoms were each associated in participants with SAD. Further, shame was shown to be elevated among SAD patients compared to the main healthy control. Following treatment, shame significantly reduced among participants with SAD. These findings suggest that shame and social anxiety are associated, that socially anxious patients may be more likely to experience shame than patients without social anxiety, and that CBT treatment can help reduce shame among individuals with SAD.
Hedman, E., Strom, P., Stunkel, A., & Mortberg, E. (April 19, 2013). Shame and Guilt in Social Anxiety Disorder: Effects of Cognitive Behavior Therapy and Association with Social Anxiety and Depressive Symptoms. Plos One, 8, 4.
Autism Spectrum Disorders (ASD) is an umbrella term representing a range of persistent cognitive deficits and impairments in communication and social interaction, often diagnosed by age two, and includes autistic disorder, Asperger’s syndrome, and pervasive developmental disorders. Children with ASD are at an elevated risk for developing anxiety disorders, which can become highly debilitating across environmental contexts (home, school, and social contexts). The results of previous research (case studies, small group studies, and randomized clinical trials) have provided evidence and support for the efficacy of modified CBT for youth with ASD and anxiety.
In a 2012 study published in Autism Research and Treatment, researchers developed a modified version of a CBT intervention (“Facing Your Fears”) for adolescents with ASD, titled “Facing Your Fears: Group Therapy for Managing Anxiety in Children with High Functioning ASD” (FYF-A). They then assessed the feasibility and acceptability of the FYF-A intervention program.
Participants included 24 adolescents and their families, age 13-18, with ASD and anxiety. They attended 14, 90-minute sessions, plus 1 booster session, which included large group activities with teens and parents, small-group activities with teens and parents alone, and dyadic work with parent and teen pairs. The program focused on core CBT components (including an introduction to anxiety symptoms and implementation of CBT strategies) and several modifications for teens with ASD. These modifications included: (1) a social skills module to address areas of social challenge; (2) parent-teen dyadic work focused on achieving a mutual understanding and shared goals; (3) the use of technology to both monitor symptoms of anxiety and remind participants to utilize CBT strategies; and (4) a parent curriculum.
At post-treatment, participants showed significant reductions in anxiety severity and intrusiveness. These reductions were maintained at the 3-month follow up. Further, nearly half of the participants met criteria for a positive treatment response on primary diagnosis following the intervention. These finding are encouraging, as they add further evidence that modified CBT for adolescents with ASD is effective in decreasing anxiety symptoms among this group.
Reaven, J., Blakeley-Smith, A., Leuthe, E., Moody, E., & Hepburn, S. (January 01, 2012). Facing Your Fears in Adolescence: Cognitive-Behavioral Therapy for High-Functioning Autism Spectrum Disorders and Anxiety. Autism Research and Treatment, 2012, 2, 1-13.
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