Many of the anxiety symptoms that our clients experience will fall into diagnostic categories, for which there are specific cognitive models and treatment protocols evolved from clinical trials. Major references for key models and protocols are summarised in Table 14.1. The publication dates for some of these references will show you that many of these models are long established.
In this chapter, we will introduce the cognitive model for each of these disorders along with the associated treatment guidelines. You will probably notice similarities across models, but it is important to note the sometimes subtle differences between them. Empirically, the subtle differences matter, as you will see later when we review treatment protocols that are based on the different models.
Table 14.1 Key models and protocols for anxiety disorders
Kirk & Rouf (2004)
Panic disorder and agoraphobia
Clark (1986, 1999); Wells (1997)
Salkovskis & Warwick (1986); Warwick & Salkovskis (1989)
Clark (2002); Clark & Wells (1995); Wells (1997)
Generalised anxiety disorder (GAD)
Borkovec & Newman (1999); Borkovec et al. (2002); Wells (1997, 2000)
Obsessive-compulsive disorder (OCD)
Salkovskis (1985, 1999); Wells (1997)
Post-traumatic stress disorder (PTSD)
Ehlers & Clark (2000)
There is, as yet, no evaluated ‘cognitive model’ of specific phobias, although a preliminary model has been proposed by Kirk and Rouf (2004). In brief, they suggest that clients with specific phobias (for example, of a particular animal or situation or of blood) are hypervigilant for threat cues. Thus, the cycle begins with:
The primary cognitions (fear of an object or a situation) exacerbate:
Beliefs about the meaning of the phobia (secondary cognitions) can also heighten anxiety, with beliefs such as ‘I am foolish’ or ‘I am going mad’ (see Figure 14.1).
Figure 14.1 A cognitive model of specific phobia
Karen had always been fearful of wasps. The thought of them made her shudder, and the sight of one triggered panic. If she saw one, she could not think straight and would run away – recently she had left her youngest child outside a shop when she ran for cover. She coped by doing all she could to avoid wasps: never going into the garden during the summer months; not allowing her children to eat sweets outdoors in case this attracted wasps; keeping the doors and windows closed in her home. It was hard for her to verbalise what made her so afraid, but she had an image of being unable to escape angry wasps caught in her hair.
Helping a client overcome a specific phobia involves:
Karen wanted to tackle her phobia head on and was prepared to try to confront a wasp. She and her therapist devised a hierarchy of graded behavioural experiments and made predictions about her probable responses to increasingly challenging wasp-related tasks. The experiments began with looking at photographs of wasps and progressed through to releasing a wasp from a jar into the garden. When she got as far as releasing wasps, she realised that they flew from rather than to her: her images of the wasps caught in her hair then diminished. This success gave her courage to work towards dropping her safety behaviours. Each lent itself to behavioural testing, and, through this, she discovered that her anxiety was heightened by her excessive hypervigilance. She also learned that if she left windows open, or let her children eat sweets outdoors, she encountered wasps, but far fewer than she had predicted, and that she coped better than she had anticipated.
Blood and injection phobias are different from other phobias as they have a different physiological maintaining pattern. As blood pressure drops in both these disorders, the client experiences unpleasant bodily and mental sensations and the prospect of fainting is real. These phobias are dealt with in Chapter 10.
A prominent cognitive model of panic disorder is that of Clark (1986), which identifies the maintaining factors as:
Figure 14.2 A cognitive model of panic disorder
When Wendy had a panic attack, her chest tightened, she fought for breath and she trembled. She felt pain in her chest and arms and experienced tunnel vision. She thought she was having a heart attack and could die. She avoided any situation where she feared she might exert herself as she feared provoking a heart attack. For example, she no longer did the weekly supermarket shop, nor took her children to the park. She knew that she was becoming physically unfit, and this heightened her fears.
The management of panic disorder typically involves:
Wendy’s therapist raised the question of whether her muscular pain and difficulty breathing could result from the muscular tension associated with her state of heightened anxiety. Wendy was eventually convinced of this when she agreed to exercise in the session – even though the prospect had frightened her and had initially provoked the predicted symptoms. Once she had exercised in the session and discovered that she was a bit breathless but otherwise okay, her belief changed to: ‘I am not having a heart attack but I am highly anxious and it will pass’. Once she had gained this new perspective, she engaged in increasingly physically demanding activity. She began by exercising in the session and then between sessions, and grew confident that a racing heart or muscular tension was not harmful to her. Ultimately, she attended a gym regularly and ceased avoiding situations that she feared would over-exert her.
Hypochondriasis or health anxiety
The cognitive understanding of health anxiety centres on the enduring catastrophic predictions concerning future health issues and preoccupation with physical symptoms (i.e. focus of attention towards the perceived threat). In itself, the fear of developing physical illness can exacerbate alarming physical symptoms, for which there is also likely to be selective awareness. This leads to high levels of anxiety. Sufferers of health anxiety tend to engage either in reassurance-seeking behaviours or in avoidance of situations they predict will heighten their anxiety (safety behaviours).
Reassurance-seeking is ineffective in changing health anxiety as it reflects a reliance on external support. Sufferers fail to learn to assure themselves, and health concerns remain intact; there is always room for doubt – ‘Maybe I didn’t fully explain my symptoms to my doctor …’, ‘Maybe I didn’t fully understand what he said – maybe he said that I could have cancer!’ Furthermore, it is not unusual for a person who repeatedly complains of potentially harmful physical symptoms to be subjected to various tests, which can be interpreted as proof of real ill-health.
Maintaining cycles can take several forms:
Tina woke each morning with thoughts that she might have breast cancer. She tried unsuccessfully to avoid the media and, instead, noticed every article about cancer. Each day she felt compelled to check her breasts, armpits and neck for signs of lumps or enlarged glands. She believed that it would be dangerous not to check, as a missed tumour could become malignant. She always found something that gave her concern, so she persuaded her partner to ‘double-check’ for her. The relief each time she was reassured was exhilarating, although short-lived.
As with GAD, the interpretation of the preoccupation needs to be explored too, as some clients hold beliefs about their continued concern, such as ‘If I am vigilant for signs of illness I will be OK’ or ‘If I think about my illness I will bring it on’.
Figure 14.3 illustrates how health anxiety can be maintained through:
The treatment approaches for health anxiety reflect these maintaining cycles and incorporate:
Figure 14.3 A cognitive model of health anxiety
Tina’s most awful thought was that she would die a lingering death that would torment both her and her loved ones. With help, she was able to review this prediction, but her relief stemmed less from the statistical data about her risk of dying of cancer than from her re-appraisal of her coping resources. Once she believed that she could tolerate a protracted death (however undesirable this might be), she focused less on her health and her preoccupation diminished.
She also believed that if she did not get reassurance, she would be unable to withstand the uncertainty, and this would undermine her ability to function. She refined her definition of ‘to function’, specifying what activities would be impaired and how. She then conducted behavioural experiments to test the validity of her predictions and learnt that she could use distraction to help her with any tasks that she needed to complete and that she often functioned better when she kept her health worries at bay. She then built on this series of behavioural experiments by testing her prediction that she would become uncontrollably preoccupied by thoughts of cancer if she read or watched the media. She discovered that she could cope.
In addition, Tina’s partner agreed to stop giving her reassurance and, although Tina initially felt uncomfortable about this, she quickly learnt to assure herself.
At her first review session, Tina reflected on her beliefs in Theory A (that she would get breast cancer and would be unable to cope) and Theory B (that her preoccupation and safety-seeking kept health concerns foremost in her mind). She concluded that she now felt that Theory A was unlikely and she believed 80% in Theory B.
As we said in Chapter 13, social anxiety can be in the more severe form of social phobia or the milder ‘shyness’. Some social anxieties are quite specific, only arising when meeting a new person or an attractive person, for example, or only when carrying out particular tasks such as writing or eating in public. Sometimes the anxiety is more pervasive.
Cognitive models for social phobia have been developed (see Figure 14.4), most notably by Clark and Wells (1995), which, suggest Butler and Hackmann (2004), are readily applicable to ‘shyness’. Models of social phobia incorporate the following:
Figure 14.4 A cognitive model of social anxiety
Bette anticipated rejection. Her prediction in social situations was that others would realise that she had nothing to offer and would not want to know her. If someone did show interest, she discounted it: ‘They don’t know the real me’, or ‘They were just being polite’. As far as possible, she avoided social gatherings, and when she attended them, avoided eye contact but could ‘feel’ the critical gaze of others. She tended to busy herself attending to the practical needs of guests. If she became involved in conversation, the intensity of her negative intrusive thoughts rendered her unable to chat.
Interventions for social phobia involve:
o Are the symptoms you fear actually as likely to happen as you fear?
o Even if they do happen, will it actually be as severe as you imagine?
o Even if it is, will other people actually notice?
o Even if they do notice, will they interpret it in the way that you fear they will?
o Even if they do see it that way, so what? Is it possible you can survive it and get on with your life?
Bette learnt several strategies to combat her social anxiety. First, she described her worst-case scenario and challenged her predictions that (i) she would almost certainly be criticised and ostracised and (ii) that she would not cope with criticism but would accept it and become deeply depressed. Cognitive restructuring, developing a strong but caring inner voice and role play with her therapist helped her to conclude that she was unlikely to be openly criticised, but even if she were, she could stand up for herself and not spiral into despair. She also learnt strategies to refocus attention from her negative, self-referent thoughts. In addition, she carried out behavioural tests: she allowed her therapist to log the number of people who looked at her critically when they attended a social gathering – to her surprise, the therapist noted no one. Finally, she engaged in a series of assignments focused on not tending to guests’ practical needs (i.e. dropping her major safety behaviour). As she progressed through the hierarchy of assignments, she built her confidence that she could mix socially.
Generalised anxiety disorder (GAD)
As described in the previous chapter, GAD is defined as chronic, excessive anxiety and worry pertaining to a number of events or activities (DSM-IV-TR; APA, 2000).
Sam was 64 years old and felt he should be looking forward to his retirement – his wife certainly was. However, as usual, he was beset with worries about it: What if he and his wife did not get on? What if their financial planning had been insufficient? He found his worrying shameful but familiar, and he could not remember a time when he had been free of it, just times when it was slightly better or worse.
Cognitive models of GAD give prominence to worry as a key cognitive factor. There are several possible mechanisms for persistent worry:
Treatment for GAD focuses on breaking the worry cycle by understanding and eliminating unhelpful worry and then helping your client address the underlying fears.
Figure 14.5 A cognitive model of GAD
The required steps include:
Sam was encouraged to articulate his fears: he said that he was terrified that his wife would realise he had nothing to offer her and would leave him; that they would run out of money and be unable to afford decent health care; that his wrong decision in taking retirement would cost him his marriage, his security and, worst of all, would prove that he was useless. By using cognitive strategies, he was able to both de-catastrophise specific negative thoughts, but also to appreciate his resilience (he had managed many personal and business crises in the past) and that enabled him to tolerate the uncertainty of his future. Throughout, there was a theme of shame, worthlessness and responsibility, and these general negative themes were also reappraised.
Sam carried out a behavioural experiment comparing his ability to problem-solve when he focused on his worries with his ability to do so when he distracted himself from them. He learned that worrying was counterproductive and recognised that it had become both a habit and a source of comfort, as he believed that he could ward off bad luck by worrying. Once he understood this, he readily distracted himself from worrying, thus breaking an unhelpful pattern.
Obsessive-compulsive disorder (OCD)
Unwanted intrusive thoughts, in the form of words, images or impulses, are not in themselves pathological (Rachman & de Silva, 1978), so we would not attempt to challenge them, but the response to them can be unhelpful. Cognitive models of OCD share the basic premise that intrusive thoughts are in themselves normal but become a problem when they are interpreted as indicating that something bad might happen and that the sufferer is responsible for preventing it. To manage this fear, the sufferer engages in safety behaviours (avoidance, reassurance-seeking and cognitive or motor rituals), which prevent him from learning that his worries are not accurate or that his anxiety will actually decline without his performing rituals. The aim of CBT is for the client to learn that such intrusive thoughts do not indicate a need for action and can safely be ignored.
The most common obsessional worries relate to:
The most common safety behaviours are:
Most OCD sufferers have motor rituals, but some have predominantly cognitive rituals with few if any motor rituals (so-called ‘pure obsessions’ – a presentation that may be harder to treat).
Vince had always been very cautious and was proud of his high standards for safety. However, since a promotion (with responsibility for ensuring departmental security), his safety checks had become exaggerated and he was now struggling to leave the building at night. He often returned five or six times to recheck – occasionally driving in from his home. He tried unsuccessfully to put the worrying thoughts out of his mind. His fear was that insufficient caution would result in a catastrophe for which he would shoulder the blame. He thought that the shame of this would destroy him.
It has been suggested by the Obsessive-Compulsive Cognitions Working Group (1997), that the key cognitions in OCD are:
As with other anxiety disorders, thoughts about negative thoughts (e.g. ‘There must be something fundamentally wrong with me for having such thoughts’) can heighten anxiety (Wells, 2000). Emotional reasoning (the assumption that feelings are a reliable source of information about a situation – for example, ‘I feel anxious, therefore this must be a dangerous situation’) is also common amongst sufferers of OCD (Emmelkamp & Aardema, 1999) (see Figure 14.6).
Figure 14.6 A cognitive model of OCD
Interventions for OCD incorporate:
Vince’s most unhelpful belief was: ‘I am wholly responsible for any crisis that arises at work’. He challenged this by recognising the cognitive biases in his thinking and by constructing a ‘responsibility pie’ (see Chapter 17), which helped him to apportion responsibility more realistically. However, he also had to work on the dichotomous thinking that underpinned his unrealistically high standards: continuum work (see Chapter 17) helped him to become more flexible. He addressed other key beliefs such as ‘I will be destroyed if I am to blame’ using standard cognitive interventions.
Feeling more confident that he could tolerate the worst-case scenario, he agreed to a programme to reduce his safety behaviours. This incorporated an agreement that his wife would not reassure him when he was at home feeling uneasy about his department’s security. He struggled initially with refocusing his thoughts away from catastrophic possibilities. He kept (meticulous) diaries of his experiences, and these showed clearly that he felt less anxious and more content on the days that he reduced safety behaviours and catastrophic thinking. He also recognised that catastrophes never ensued at these times, giving him evidence that his safety behaviours were not necessary.
Several cognitive models for PTSD have been developed over the past decade but the most prominent is probably that of Ehlers and Clark (2000). Cognitive models tend to put an emphasis on:
These memories are emotionally highly provocative and remain so for several reasons:
In addition, the cycle of PTSD can be maintained by:
See Figure 14.7.
Figure 14.7 A cognitive model of PTSD
Alistair had been involved in a road-traffic accident when his car tyre exploded at high speed. He had had a lucky escape. Eight months later, he still experienced vivid memories of his car flipping over, memories of the sights, sounds and smells as if it were happening again. For him, everything went black again, he heard metal scraping along the road, sounding like an old train braking; he felt as if he were hanging upside down and each time he again had the thought: ‘I’m going to die’. He was particularly likely to have flashbacks when he smelled petrol or when he returned to the area where the accident took place. Therefore, although he still drove his car, his partner would always refuel, and he never drove near the site of the crash.
Treatment for PTSD based on the cognitive models involves addressing:
Alistair’s intrusive memories responded well to cognitive restructuring. Ultimately, his therapist helped him to talk through his experience as if it were currently happening, pausing at the emotional ‘hot spots’ to review his cognitions in the light of what he now knew. By doing this, Alistair was able to challenge his most salient thought: ‘I am about to die’. He was able to remind himself that he got out of the crashed car with few injuries and, in doing so, he reduced the intensity of the flashbacks. He was also able to revise a shameful belief which had developed after the accident, namely that he was responsible for the incident. This further reduced the anxiety that the memories evoked.
He was gradually able to revisit the site of the crash – first with his partner and later alone – and to talk and read about accidents. His predictions that he would have flashbacks were not borne out, and his confidence returned. His avoidance of smelling petrol was more difficult to tackle, as fears associated with smells are particularly resilient, but because he had learnt to be less afraid of flashbacks, he tolerated the occasional vivid memory without undue distress, and he no longer felt the need to avoid the smell of petrol.
The precipitants of PTSD may be impersonal, such as a natural disaster, or perceived as highly personal, for example when a person has been assaulted in some way. In cases of personal attack, there is likely to be a need for greater sensitivity to interpersonal relationships both within and outside the therapy setting. Some clients will have experienced sexual assault and, clearly, there needs to be sensitivity when discussing this and other sexual relationships.
Anxiety disorders can present as discrete problems, in combination with other anxiety disorders or as co-morbid with other problems – for example, the high standards of the person with OCD might predispose her to an eating disorder, the chronicity of an anxiety problem might give rise to depressed mood, while coping strategies such as comfort eating or drinking can develop into difficulties in their own right. Remember to take this into account during your assessment, and throughout treatment remain aware that other problems might exist.
The previous chapter reviewed a generic understanding of anxiety disorders, while this chapter has focused on specific models and the treatment approaches linked to them. In your practice, you will need to be aware of both the generic and specific approaches so that you can be flexible and responsive to your client’s needs. The models give an elegant and invaluable understanding of particular anxiety disorders, while the generic overview provides you with the ‘first principles’ that you can fall back on if the models and protocols do not meet your client’s needs.
Potential problems when working with specific models and treatment protocols
Assuming the validity of a diagnosis without carrying out a full assessment and then adhering to a treatment protocol
Although many of your clients will fulfil criteria for a particular diagnostic group and will benefit from a protocol-driven approach, do not presume this without carrying out a proper assessment. There will be times when the referrer’s diagnosis or your first impressions are wrong.
Trying to force a client’s experiences into a specific model
Keep a curious and open mind during your assessments. If your client’s presentation does not fit neatly into the model that you anticipate being relevant, perhaps the model is invalid for this person. In such instances, a generic formulation (Beck et al., 1979) will be appropriate and this will guide you in deciding which interventions might be best.
Sticking too rigidly to a protocol when the client is not responding well
While it is important to follow a protocol, there will be individual differences amongst your clients and aspects of their presentation which, at some point, may not fit with the protocol. In some instances, the deviation will be sufficiently marked for you to have to reassess your client and consider if the protocol offers the optimum approach. At other times, staying with the protocol will be in your client’s best interest, but you may need to adapt it slightly – for example, introducing a session on specific skills training (assertiveness, time management and so on) or temporarily diverting to tackle an issue that appears to obstruct progress, issues such as excessive anger, unresolved grief or flashbacks.
i a generic understanding of the factors that contribute to, and maintain, anxiety-related difficulties so that you can formulate the problems of your clients who do not fit the standard models and,
ii an appreciation of the range of management strategies you can apply to breaking the cycles that maintain anxiety disorders so that you can be flexible in your approach when this is necessary.
Review and reflection:
Taking it forward:
Wells, A. (1997). Cognitive therapy of anxiety disorders: a practical guide. London: Wiley Blackwell.
A well-established ‘basic’ text, which addresses the various anxiety disorders in a practical and informative way. It is comprehensive and successfully marries theory and practice.
Butler, G., Fennell, M., & Hackmann, A. (2008). Cognitive-behavioural therapy for anxiety disorders: mastering clinical challenges. New York: Guilford Press.
A wise and excellent formulation-based approach to treating anxiety disorders which remains evidence-based in its recommendations for intervention. It is extremely readable yet avoids oversimplifying the management of anxiety disorders.