Integrative CBT for Anxiety Disorders

An Evidence-Based Approach to Enhancing Cognitive Behavioural Therapy with Mindfulness and Hypnotherapy

Assen Alladin

• Publisher: Wiley-Blackwell
• Year: 2015
• ISBN:
  9781118509913
• Edition: 1
• Topic: Psicología
• Subtopic: Terapia cognitiva conductual (TCC)

Integrative CBT for Anxiety Disorders applies a systematic integrative approach, Cognitive Hypnotherapy (CH), to the psychological treatment of anxiety disorders; it demonstrates how simple techniques can be used to create a therapeutic context within which CBT is more effective.

• An evidence-based approach to enhancing CBT with hypnosis and mindfulness when treating anxiety disorders shows how simple techniques can be used to create a therapeutic context within which CBT can become more effective

• Offers detailed and comprehensive coverage for practitioners, with specific protocols for each anxiety disorders covered and a hort case study per treatment chapter in order to demonstrate the approach in action

• Anxiety disorders is an area where the interaction between conscious and unconscious processes is especially important, and where the use of hypnotherapeutic and mindfulness techniques can therefore be especially effective

• Builds on the author's research and experience and develops his significant earlier work in this area – notably Cognitive Hypnotherapy: An Integrated Approach to the Treatment of Emotional Disorders (Wiley, 2008)

1
An Integrative Approach for Understanding and Treating Anxiety Disorders

Overview

This chapter reviews the concept of wounded self, which provides a common thread for binding the best extant theoretical constructs and the most effective treatment strategies for anxiety disorders into a comprehensive integrated model. The focus of this theoretical integration is the concept of self-wounds or early unresolved emotional injuries. This model offers an integrative perspective on the nature, development, aggravation and maintenance of anxiety disorders. According to this view, anxiety represents an unconscious fear of unbearable insult to the wounded self. This chapter describes SMAD and outlines the theoretical and empirical rationale for integrating CBT, mindfulness and hypnotherapy in the psychological management of anxiety disorders.

Introduction

Although anxiety disorders constitute the most common psychological disorders treated by mental health professionals and family physicians, a coherent etiological theory and a comprehensive integrated treatment for anxiety disorders are lacking. From his review of the literature, Wolfe (2005) found mainstream views of anxiety disorders to be flawed in respect to their conceptualization, etiological theories, treatment approaches, research hypotheses and research methodologies. He noticed that none of the current perspectives on anxiety disorders, including psychoanalytic, behavioural, cognitive-behavioural, experiential, and biomedical, provide a complete theory or a comprehensive treatment for anxiety disorders, albeit each viewpoint has made some important contribution to our understanding and treatment of the disorders. He also noted that none of the etiological theories upon which the current treatments are based on accentuated the role of interpersonal, family, cultural and ontological factors in the formation, onset and course of anxious symptoms. To rectify these shortcomings, Wolfe has developed an integrated perspective of anxiety disorders that accesses the best theoretical constructs, the most effective treatment strategies and specific evidence-based techniques from various existing etiological theories and treatment approaches. Before discussing the clinical implications of this integrated perspective of anxiety disorders, the main components of Wolfe’s model are described and, where relevant, expanded on.

Self-Wounds Model of Anxiety Disorders

To differentiate from other models of anxiety disorders, the integrated perspective described in this book is referred to as the SMAD. The model consists of two interrelated theories: the integrative etiological theory of anxiety disorders and the integrative psychotherapy for anxiety disorders. Both theories represent a synthesis of major extant perspectives of anxiety disorders and their treatments (Wolfe, 2005, 2006). The focus of both the integrated etiological model and the unified treatment is the concept of self-wounds, which in the most general sense can be defined as the patients’ chronic struggles with their subjective experiences. The components of SMAD are first discussed before describing the integrated psychotherapy based on the model.

Origin of self-wounds

Self-wounds result from interaction between damaging life experiences and cognitive and emotional strategies that are used to protect oneself from anticipatory catastrophes. Wolfe (2005, 2006) derived the notion of wounded self from his observation of patients with anxiety disorders. He noticed that in most of these patients, the anxious symptoms appeared to represent an implicit (unconscious) fear of unbearable catastrophe to their physical and psychological well-being (exposure of unbearable painful views of the self). Based on this observation, he hypothesized that the experience of severe anxiety in selected situations gives rise to conscious anticipations of impending calamity, which at an unconscious level, represents fear of exposing unbearable painful views of the self. In this sense, the etiological theory of anxiety disorders consists of two layers of information processing – the first layer comprises conscious awareness of anxiety symptoms resulting from anticipatory catastrophes and the second layer entails implicit or unconscious interpretations of what the anxiety symptoms mean to the patient (see Figure 1.1).

Figure 1.1 Schematic model of an anxiety disorder.

(adapted from Wolfe, 2005, p. 112)

Anxious patients believe that exposure of their self-wounds, either to themselves or to others, will produce overwhelming affects, such as humiliation, rage, despair and loss of control, which they desperately want to avoid. These painful views of the self in turn create a feeling and experience that the patient will not be able to cope with the vicissitudes of life. This observation is supported by Kendall and Hollon (1989), who found patients with high levels of anxiety to have automatic thoughts about uncontrollability, threat or danger. Since the rigors and realities of everyday living are unavoidable, anxious individuals develop maladaptive coping strategies such as behavioural avoidance, rumination with cognitive distortions, preoccupation with symptoms and emotional constriction to protect themselves from facing objects and situations that are perceived to produce distressing affect. Unfortunately, these indirect manoeuvres often produce unintended interpersonal consequences (Alden & Taylor, 2004), which reinforce the patient’s painful core beliefs about the self (Whisman & Beach, 2010). Moreover, these strategies keep the person away from facing his or her fears and self-wounds head-on, resulting in the perpetuation of the symptoms. Furthermore, in response to the initial anxiety, patients get into the habit of cogitating about being anxious and consequently become anxious for feeling anxious (Goldstein & Chambless, 1978).

Negative self-hypnosis in anxiety disorders

Alladin (1994, 2007, 2013a, 2014a) has depicted the similarities among the concepts of cognitive distortions, cogitation, rumination, worry and negative self-hypnosis (NSH). Although there are some subtle differences among these concepts, there are more similarities. For example, studies by Fresco, Frankel, Mennin, Turk and Heimberg (2002) and Segerstrom, Tsao, Alden and Craske (2000) found repetitive thought to be a common factor in measures of worry and rumination. Moreover, all the five constructs mentioned earlier are typically negative in valence, repetitive, perseverative, self-focused, overgeneralized, and they are all associated with cognitive inflexibility and difficulty in switching attention from negative stimuli. They also lead to performance deficits, difficulties in concentration and attention, poor problem solving, inadequate solution implementation and exacerbation of symptoms (Papageorgiou & Wells, 2004).

Cognitive distortions

Cognitive theorists have always asserted that preoccupation with cognitive distortions – related to threat, danger, loss of control and inability to cope – to be one of the key elements of cognitive theories of anxiety disorders (Beck, 1976, 2005). For example, Barlow (2002, p. 104) defined anxiety as ‘a future-oriented emotion, characterized by perceptions of uncontrollability and unpredictability over potentially aversive events and a rapid shift in attention to the focus of potentially dangerous events or one’s own affective response to these events’. Similarly, Clark and Beck (2010, p. 5), in their recent volume on anxiety disorders, stated that anxiety is a complex cognitive, affective, physiological and behavioural response system (i.e., threat mode) that is activated when anticipated events or circumstances are deemed to be highly aversive because they are perceived to be unpredictable, uncontrollable events that could potentially threaten the vital interests of an individual.

Cogitation

According to Wolfe, cogitation, or the preoccupation with symptoms, serves anxious patients one of the main defence strategies for protecting themselves from the ‘excruciatingly painful view of the self’ (p. 117). Rather than exploring the implicit meaning of their anxiety, anxious patients tend to detach from themselves and become absorbed in the imminent catastrophe they expect will occur. This form of catastrophizing is very characteristic of cognitive distortions described by CBT therapists (e.g., Beck, 1976, 2005), rational-emotive behaviour therapists (Ellis, 2005) and cognitive hypnotherapists (Alladin, 2014a).

Rumination

Rumination has also been equated with recurrent negative cognitive style of thinking (Martin & Tesser, 1989, 1996). Rumination can be defined as repetitive negative thinking (Hazlett-Stevens, Pruit, & Collins, 2009) associated with various psychopathologies, including anxiety, binge eating, binge drinking and self-harm (Nolen-Hoeksema et al., 2008; Papageorgiou & Siegle, 2003 for review). Nolen-Hoeksema (1991) has been instrumental in advancing our knowledge of ruminative thinking in depression. She proposed the response styles theory of depression to explain the insidious relationship between rumination and depression. According to her response styles theory, rumination is a mode of responding to distress that involves repetitively and passively focusing on symptoms of distress and on the possible causes and consequences of these symptoms. Rumination does not generate active problem-solving strategies for changing the circumstances surrounding the symptoms, instead it keeps patients fixated on the problems and their feelings. There is strong evidence that rumination exacerbates depression, enhances negative thinking, impairs problem solving, interferes with instrumental behaviour and erodes social support (Nolen-Hoeksema, 1991; Papageorgiou & Wells, 2004). The content of ruminative thought in depressed people is typically negative in valence, similar to the automatic thoughts, schema and negative cognitive styles that have been studied extensively by cognitive theorists (e.g., Beck, 1967, 2005). In addition to depression, there is evidence that rumination is associated with other psychopathologies, including anxiety, binge eating, binge drinking and self-harm (Nolen-Hoeksema et al., 2008).

Pathological worry

Given the high comorbidity between anxiety and depression, rumination is known to increase the risk for anxiety disorders as well as depression (Nolen-Hoeksema et al., 2008). Anxiety disorders, however, involve a different form of perseverative thought pattern from depression that is typically characterized by excessive or pathological worry (Borkovec, 1994; Papp, 2010). Based on empirical literature, Borkovec, Robinson, Pruzinsky and DePree (1983, p.10), define excessive worry as a chain of thoughts and images, negatively affect-laden and relatively uncontrollable. The worry process represents an attempt to engage in mental problem solving on an issue whose outcome is uncertain but contains the possibility of one or more negative outcomes. Consequently, worry relates closely to fear process.

The experimental study of worry began in the 1970s within the context of test anxiety, and by the early 1980s worry was delineated as a common cognitive process associated with states of anxiety (Hazlett-Stevens et al., 2009). This research found worry to be characterized by concerns about the future rather than the present and to be associated with feelings of anxiety, apprehension and general tension. Individuals with high levels of worry were also found to have more uncontrollable cognitive intrusions, poorer ability to focus attention on an experimental task and greater subjective anxiety than ‘non-worriers’. In a recent study (Mennin, Heimberg, Turk, & Fresco, 2005), individuals with GAD were noted to have greater tendency to avoid negative experience related to stress, anxiety and emotional responding. Excessive or unrealistic worry is therefore regarded as the central defining feature of GAD (American Psychiatric Association, 2013) and is present in most of the anxiety disorders (Barlow, 2002). Rumination and worry have been found to be significantly correlated with each other (Fresco et al., 2002; Muris, Roelofs, Meesters, & Boomsma, 2004; Segerstrom et al., 2000; Watkins, 2004; Watkins, Moulds, & Mackintosh, 2005), and they share many characteristics (McLaughlin, Sibrava, Behar, & Borkovec, 2006). For example, they are both self-focused, repetitive, perseverative and overgeneralized forms of thinking (Barlow, 2002; Borkovec, Alcaine, & Behar, 2004; Segerstrom et al., 2000; Watkins, Teasdale, & Williams, 2000). Moreover, both are associated with cognitive inflexibility and difficulty in switching attention from negative stimuli (Davis & Nolen-Hoeksema, 2000; Hazlett-Stevens & Borkovec, 2001). These cognitive styles lead to performance deficits, difficulties with concentration and attention, poor problem solving and inadequate solution implementation (Davey, 1994; Lyubomirsky & Nolen-Hoeksema, 1995; Lyubomirsky et al., 1999; Ward et al., 2003; Watkins & Baracaia, 2002; Watkins et al., 2005). Consequently, both rumination and worry have been found to exacerbate symptoms of anxiety and depression (Abbott & Rapee, 2004; Barlow, 2002; Fresco et al., 2002; Harrington & Blankenship, 2002; Kocovski et al., 2005; Muris et al., 2005; Nolen-Hoeksema, 2000; Nolen-Hoeksema & Morrow, 1991; Schwartz & Koenig, 1996).

Worry, in anxiety disorders, tends to be future-oriented and centres on dangers that might occur but have not yet occurred. Barlow (2002) indicated that even when patients with anxiety disorders worry about something that has happened in the past – such as making a mistake in a social situation – they often worry about the implications of this event for the future (e.g., ‘Now everyone will think I am an idiot.’). Moreover, patients with GAD tend to have uncontrollable worry about minor topics more often than non-anxious individuals (Craske, Rapee, Jackel, & Barlow (1989). GAD is thus believed to be maintained by meta-cognitive beliefs about the functions and consequence...

Table of contents

• Cover
• Title Page
• Table of Contents
• About the Author
• Foreword
• Preface
• Acknowledgements
• 1 An Integrative Approach for Understanding and Treating Anxiety Disorders
• 2 Integrated Therapy for Anxiety Disorders
• 3 Social Anxiety Disorder (Social Phobia)
• 4 Specific Phobia
• 5 Panic Disorder
• 6 Generalized Anxiety Disorder
• 7 Agoraphobia
• 8 Separation Anxiety Disorder
• 9 Selective Mutism
• 10 Conclusions and Future Directions
• Appendix A: Appendix 1A: Cognitive-Hypnotherapy Case Formulation and Treatment Plan
• Appendix B: Cognitive-Hypnotherapy Case Formulation and Treatment Plan
• References
• Index
• End User License Agreement