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Cognitive Therapy of Anxiety DisordersReview - Cognitive Therapy of Anxiety Disorders
Science and Practice
by David A. Clark and Aaron T. Beck
Guilford Press, 2009
Review by Roy Sugarman, PhD,
Mar 29th 2011 (Volume 15, Issue 13)

Both authors are well known to anyone in the field.  Given the manualized philosophy of CT and CBT, this has become the most researched trend in delivering psychotherapy in anxiety disorders.

Three sections of the book expose the last few decades of advancement in this field, given this burgeoning research.

The first elaborates on the original models that began to emerge in the mid 80's, the second, the strategies that emerge across the anxiety disorders as putative treatments, and the last, more specific approaches to the individual diagnoses within the anxiety nosology.  This is all in keeping with Beck's commitment to empiricism in demonstrating what is now considered the evidence base for the interventions which come under the heading of CT.

Chapter one examines anxiety and fear, as if for the lay person who does not understand the conditions, or the difference between a fear, and fear of the unknown, but also to reiterate what exactly is the approach to these conditions as they are described.  Once anxiety and fear are distinguished, and of course Barlow's definitions are invoked, then the idea of what might be considered functional and thus normal, and what might be abnormal and leads to dysfunction, are of course in keeping with the DSM's over the years, in that any condition which might otherwise be considered normal, eg not doing maths, becomes abnormal if it leads to dysfunction. Any fear or grief or anxiety is only really to be considered pathological if it leads to an inability to deal with events in life which should ordinarily be coped with. The other common issue with anxiety, is its comorbidity with other conditions, the most ubiquitous being depression, living alongside as a diagnosis in about 55% of cases, as high as 76% when taken as a lifetime statistic. Not only intra-category, there is comorbidity with other anxiety disorders as well.  In fact, comorbidity is more common than individual conditions appearing without another category, confirming what Steve Hyman wrote about in Nature Reviews Neuroscience, when he noted the lack of distinct categorization in clinical diagnosis, which did not mirror the DSM manuals.  Symptom frequency and intensity are thus variable and an integral part of the assessment.

The role of the two major branches of the autonomic nervous system is examined, with diminished autonomic flexibility exhibited in chronic sufferers, as Selye suggested it should. The role of the sympathetic branch is well understood, the role of the moderating response from the parasympathetic less so.  The work of various researchers into heart rate variability has demonstrated more clearly the relationship between the two branches.  Barlow of course noted that anxiety prone individuals typically exist in a state of constant hyperarousal despite an absence of a direct stimulus: anxiety is a forward looking state after all, so the role of anticipation has to be researched. As Montaigne said, he had lived through many disasters, both big and small, most of which never happened at the end of the day. One of my colleagues noted that for depressed people, the worst had happened, but for anxiety prone individuals, the worst is yet to come.  For the chronic cases, heart rate variability studies demonstrate lower cardiac vagal control.  The wider neurophysiology and neurotransmitter systems are examined in light of recent findings.  Balancing this, behavioral theories are explored, including conditioning, fear module, and the case for cognition obviously given the tone of the book.  As opposed to the unitary role of the amygdala which was part of earlier thinking, other areas of the brain, and other sensitivities of the amygdala are discussed. The case is clearly also to be made of the role of the higher levels of cortical functioning in containing or modifying the fear response.

Given the tone, the second chapter speaks to the cognitive model of anxiety, based in the primary and secondary appraisal, and the automatic and strategic processing of a preconscious attentional bias for threat. The central tenets of the model include the exaggerated threat appraisals, heightened helplessness, (related to the strategic evaluation of response capacity), suppression of information incongruent with perceived level of threat, an impairment of reflective capacity, so constructive modes of problem solving are less accessed.  Clinician guidelines throughout the book deliver the take home message that each section delivers. A fuller description of the cognitive model follows, beyond those already mentioned, demonstrating the quarter century of advancement which resulted in some modification of the original model. The 12 hypothesis of the cognitive model of anxiety are put forward in their revised format.

Given Beck's original bent towards empiricism, the next chapter covers the empirical status, healthy as it is, of the cognitive model.  The 12 hypotheses are examined one by one, to establish the evidence base for each.  E.g., the idea of an attentional bias to threat is testing by instruments such as the Emotional Stroop, looking at the interference effect of anxiety provoking stimuli on the response to presented colored words. The diminished attentional processing of safety, hypothesis two, can be demonstrated, and exaggerated stress appraisals can likewise be demonstrated, by word stem completion for instance.  Up to number 10 is examined.

Selye and others have spoke of a diathesis, or vulnerability to stress and anxiety, and this is the subject of the 4th chapter. This is both variable, and not as well researched as the treatments, which of course reflects the industry that has grown around treatment and the research funds available for subjects related to anxiety.  Another issue is the silence of this vulnerability until a precipitating event.  There may be many vulnerability domains which can overlap and compound, making the disorder variable in severity in different individuals. There is no doubt that negativity, or neuroticism, has an influence, as do trait anxiety, a related concept, as does the fear of anxiety, namely sensitivity which may involve avoidance. Diminished personal control, or a fear of loss of efficacy is also discussed here, with helplessness and hopelessness related to control, a feature in the comorbidity with depression, seen as an end state when control of future events is seen as compromised. The cognitive model of vulnerability is then evaluated, namely from the perspective of Beck originally that in essence it arises from an evaluation of what the threat might be, versus what the capacity to deal with the threat might be as perceived.  Within this, genetic, biological, developmental learning, negative affect, trait anxiety etc all play a part.  A more contentious issue for both the empiricism and the personal vulnerability conferred by Hypothesis 11, as examined here, remains uncertain, as does the role of self-esteem for instance in anxiety. Hypothesis 12, namely enduring threat related beliefs, and how they are triggered. Here, the evidence for the role of schemas is more compelling.  Overall, given the subject matter, the evidence presented here has to show a bias towards proving cognitive issues as a source for vulnerability, and hence a target for change.  Here, the evidence overall is slightly deficient, given research has progressed only in the last few years.

Part II of the book now turns to assessment and intervention strategies. The three aspects of assessment, namely diagnostic information, symptom frequency and severity, and personal data are discussed. There are many diagnostic tools in the toolbox, and the Beck Anxiety Inventory is of course the gold standard for the book, as well as following discussion on the Hamilton, the DASS, State-Trait Anxiety Inventory, Cognitions Checklist, Daily Mood Rating, Beck Depression Inventory II with no explanation why it stands alone here, except for the high comorbidity with anxiety.  Fear Activation assessment is described, and the various other elements well known to this model are discussed, e.g., secondary reappraisal. It's not all negative, but includes an assessment of constructive responses including spontaneous exposure, realistic threat appraisal etc with some case formulations.  A wonderful appendix includes some useful evaluation forms, as well as a quick reference guide, given the intricacy of a cognitive assessment.

The crux of the matter comes in chapter 6 which goes into the cognitive interventions, following the main objectives of cognitive interventions, such as shifting threat foci, focusing on appraisals and beliefs which direct the anxiety, the modification of such things, the normalizing of fear and anxiety, strengthening of personal efficacy, supporting a more adaptive approach to safety, etc.  Cognitive intervention strategies include education, self monitoring and identification of anxious thoughts, cognitive restructuring are also revisited as are identifying thinking errors, generating alternative explanations and testing these, as well as gathering data on threat and vulnerability appraisals. Newer skills now include attentional training, namely how to interrupt repetitive self attentional processing that supports anxiety states. Metacognitive interventions incorporate thinking about thinking, a metaposition now reflected in Metacognitive psychotherapy being offered. So discussion around an anxious thought would include a discussion not of the consequences or likely outcome, but of what elements of such a thought constitute the threat.

Imaginal reprocessing is another newer innovation, involving reviewing imagery connected to the anxiety in its own right, and involving written descriptions in expressive narrative, to be used in later exposure techniques.  Mindfulness based cognitive therapy and acceptance and commitment therapy have come into existence, with the cognition in ACT more a description of thought as a private behavior, rather than cogntion.  In these ways, moderation of appraisals of threat, safety seeking and vulnerability are approached within anxiety, using both more now traditional approaches to CT, and at least addressing some of the more novel, offshoots of that core field.  However, when attending some of the newer workshops on these approaches, one hears very old names invoked, dating back to the family therapy movement and Eriksonian hypnotherapy.  Again, the appendix contains the names of helpful manuals and various therapy monitoring forms are available for copy.

Ch 7 then begins to explore the importance of behavioral intervention from a cognitive perspective, given the frequent existence of avoidance and escape behavior so common in aversive experiences of anxiety. Hence, behavioral assignments remain vital in disrupting the behavior: in a sense, the disorder's impact is more than a bad feeling, and more of the dysfunction that avoidant behavior might bring, especially in severe cases of PTSD or OCD.  Changes in thinking patterns which have become dysfunctional are thus targeted by behavioral tasks which provide experience and challenge of cognitive misappraisals. As has always been the case, it is important, or perhaps vital that the real therapeutic impact comes in the post-task behavior when demonstrating how the 'neurotic' appraisals differed from the actual experience.  Hence Milton Erikson's hypnotic techniques involved seeing how close clients could come to their perceived loss of control setpoint, and how that could be shifted. In any event, experience under controlled intervention where complete avoidance or escape is likely, learning takes place under the same or similar circumstances where the original anxiety was learned or created.  Exposure interventions are of course the most assertive of such interventions, involving as usual, rationale discussions and training before exposure, not mindless exposure until the client stops screaming.  Often then the behavior is initially under therapeutic control, then this is titrated back, and vanishes, meaning there is both in session and between session interventions, none of this new to the established CT, B or CBT practitioner. Despite commonly held beliefs, relaxation training in moderate to severe anxiety is not really useful, and can be used as an avoidance strategy, rather than immersion during exposure. So could giving the client the option of calling for phone support for instance.  Paradoxical intention still hangs in there from strategic therapy days, with the instruction given to worsen the anxiety provoking stimulus, thus placing elements of the anxiety under client control: I am not helpless, I am actually inducing the uncomfortable behavior. So although most therapists regard any haven from anxiety as being counterproductive, judicious use might be useful.

The chapter then moves on to the in-vivo exposure related to treating the disorder under real life, not created exposure to the anxiety provoking stimulus.  Imaginal exposure is also part of this philosophy, but devalued, as nothing about simulators is as good as the real thing, although simulator training prepares the client for the real life behavioral experiment, under controlled and pre-prepared conditions.   Exposure to the physical discomfort of anxiety is also pretty much a necessity, however it is done, e.g. forced hyperventilation, so that the imagined threat presented by the scary physical sensations such as breathlessness, heart pounding, can be inoculated against.   As with all CT, BT, CBT, the response to such noxious stimuli have to be disrupted or prevented to stop escape or avoidance behaviors.  The goal as in all interventions like this, is for them to result in independent, self-guided interventions to dominate, rather than the therapist interventions. Again, rationale and training preparation is and are vital.  Directed interventions around behavior, especially using such tools as role modeling with role reversal, provides skills which can be learned and practiced.

Notwithstanding its dysfunctional role in escape or avoidance, outside of the anxious, or panicky episodes, relation training is essential as tool in creating resilience and affecting the heightened physical tone. So too is breathing retraining, but a notable omission here is the idea of Heart Rate Variability Training which is now part of the approach to recovery in athletes, and which researchers have found to use the vagal and baroreflexes attached to breathing at a rate that maximized beat to beat variability, and enhance parasympathetic tone. Gewurtz and others believe that 20mins of this a day can inoculate against stress and anxiety responses becoming evident.

Again, the chapter ends with helpful downloads in terms of forms that can be used to monitor and direct exposure and other training.

Section Three now turns to more specific interventions, and covers Panic Disorder, Social Phobia (more an American thing than British), Generalized Anxiety Disorder, OCD and PTSD. In each case, the elements of each disorder are discussed, and then the cognitive model introduced for the disorder.  Various elements of the scientific literature around the disorder are discussed, e.g., does Panic Disorder predict suicide attempts, in the absence of comorbidity?  As before, core elements of the cognitive approach to the disorder are put forward as hypotheses, and then evaluated in terms of the evidence. Therapeutic interventions are then described. Outcome studies are also discussed, given the empirical bent of the authors. 75 pages finish the book off, devoted to the scientific references mentioned in the work.

There are of course dozens of handbooks out there referring to the treatment of anxiety disorders, but still, the ones written by the master himself, Aaron Beck, and his collaborators over the years are the ones to buy before any others.  Given so much has been written in these disorders over the last decades when CT, and  CBT began to reign supreme in the scientific outcomes literature, with its manualized presentation allowing for easy standardization of treatment and thus a path to defining the efficacy of the treatment quantitatively, the warmth of the relationship requirement identified by the NIMH studies still is cogent, but what the therapist does within the warm confines of the arrangement still has to have some weight to it.

CT is a body contact sport, and involves a lot of activity on behalf of the therapist, and long gone, despite the rehashing of much that has gone before, faddishly, as best practice therapy, are the days of the passive therapist or the passive client: this is hard work, and documented work as well, measured and paced accordingly, and requiring some skill of the therapist beyond active listening. However, precisely because of the manualized and prescribed approach, some therapists I work with do unusual things with that. Recently, a colleague noted that after 24 sessions of CBT, using the best manuals, she discovered that her client had anger issues. Any client centred therapist worth her weight in reflecting empathically, namely reflective listening, would have picked that up within minutes, or certainly within the first sessions.  Therapy had gone nowhere until then, and compliance with homework tasks etc had been limited, until the anger was dealt with by cognitive restructuring and challenge. Although CT is a powerful and well proven tool, there are other aspects to body contact sports such as psychotherapy, where being face to face with a client, rich in diversity of emotion, behavior and thought, requires more engagement than just is evident from the manual. However, within CT this is not demeaned, and must be included in the general establishment of the relationship in which the client has to encounter their own resolve to change. The seduction of such wonderful books should not detract from the need for wider skills, in which both authors were originally trained.  The word empathy does not appear in the index, and yet the NIMH studies did identify the warmth of the relationship as a really powerful factor in therapy.  Those who thus warm to the stellar techniques which Beck exemplifies and has elaborated over time, should not neglect the need to be an accomplished listener, and a human being, capable of a warm therapeutic alliance in which patients are willing to adopt these new behaviors, not just be compliant. One of my own patients described, his brain injury and experience of a skilled CT therapist, as follows: "this was good advice I just couldn't take".  Worse, his addled working memory did not allow him to follow the chain of thoughts and events, so his treatment failed.

CT has become and will remain the gold standard against with other treatments, including drugs will be measured, owing to the great Beck and his followers, and rightly so. Skills in this are essential, especially in anxiety and depression.  The well rounded therapist will however require more tools in the toolbox than just these, but what CT has done is allow problem based learning to educate psychologists and bring them to competence in the most common disorders they will ever see. When they are being trained, this is the book they will learn from, and use throughout their careers.


© 2011 Roy Sugarman


Roy Sugarman PhD, Director: Applied Neuroscience, Athletes Performance and Core Performance, USA


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