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Anxiety & related disorders > Case 3 - Exposure therapy, cognitive behavioural theory & safety behaviours > Flashcards

Case 3 - Exposure therapy, cognitive behavioural theory & safety behaviours Flashcards

1
Q

What are the key concepts of cognitive theories across anxiety disorders?

A
  1. Appraisal (interpretation bias) - interpretation of stimuli
  2. Schemas
  3. Maintenance of cognitive schemas
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2
Q

list the two types of appraisals

A
  1. Appraisal of situations
  2. Appraisal of symptoms
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3
Q

Explain appraisal of situations

A
  • Excessive fear & anxiety = consequence of exaggerated threat appraisals in harmless situations.
  • appraisal = key process that determines individual’s emotional & behavioural response to a given situation
  • Appraisals are experienced as negative automatic thoughts in response to situations that are relevant
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4
Q

What is primary appraisal?

A

Primary appraisal → immediate appraisal of a situation as threatening
* perceived probability of harm (e.g., “My mind will go blank & won’t know what to say”),
* perceived severity or costs of the harm (e.g., “People will think I’m incompetent & reject me”),
* perceived safety estimates (e.g., “Nobody will help me”)

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5
Q

What is secondary appraisal?

A

individual’s perception of how well he or she will be able to cope with this threat.

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6
Q

What is reappraisal?

A

appraisals aren’t static but updated as situation unfolds so, reappraisal of threat and/or ability to cope can take place.

an assessment of something or someone again or in a different way.

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7
Q

Explain appraisal of symptoms

A
  • Not only related to external stimuli but also symptoms of anxiety or thoughts, feelings & bodily sensations.
  • PD - catastrophic appraisal of bodily sensations lies at core of disorder
  • GAD - interpret changes in physiological arousal in a catastrophic way.
    GAD sufferers appraise own worrying in a threatening way where they are worried that excessive worrying can be a threat to their physical and psychological health. Worry about a worry
  • PTSD - typically report catastrophic interpretation of their own symptoms.
  • OCD - negative appraisal of intrusive obsessional thoughts is key factor in maintenance of OCD.
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8
Q

Explain appraisal of symptoms

A
  • Not only related to external stimuli but also symptoms of anxiety or thoughts, feelings, and bodily sensations.
  • Panic disorder - catastrophic appraisal of bodily sensations lies at core of disorder
  • GAD - interpret changes in physiological arousal in a catastrophic way.
    GAD sufferers appraise own worrying in a threatening way where they are worried that excessive worrying can be a threat to their physical and psychological health. Worry about a worry
  • PTSD - typically report catastrophic interpretation of their own symptoms.
  • OCD - negative appraisal of intrusive obsessional thoughts is key factor in maintenance of OCD.
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9
Q

What are schemas?

A

patterns of thinking & behavior that people use to interpret the world

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10
Q

How are maladaptive schemas & resulting exaggerated threat appraisals maintained by?

A
  1. Biassed information processing
  2. Safety-seeking behaviour
  3. Engagement in maladaptive cognitive strategies
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11
Q

Explain biassed informaiton processing with regards to maintenace of maladaptive schemas & exaggerated threat appraisals

A
  • Activation of cognitive schemas = conscious threat appraisals in relevant situations & guides information processing on more automatic level.
  • Maladaptive schemas are activated → threat-related information being processed predominantly & safety-related information being less important in the information-processing system (maintenance of maladaptive schemas)

Schemas bias information processing → mainly schema-consistent information is processed → preventing the schema from being updated by exposure to corrective information.

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12
Q

How is information processing biassed toward enhanced processing of threat in anxiety disorders?

A
  • Attentional bias toward disorder-specific threat
  • Interpretation bias = ambiguous information is interpreted consistent with disorder-specific threat-related schemas
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13
Q

Explain safety seeking behaviour with regards to maintenace of maladaptive schemas & exaggerated threat appraisals

A
  • Cognitive theories propose: avoidance prevents exposure to corrective information, which should = maintenance of maladaptive schemas.
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14
Q

What is safety-seeking behaviour?

A

Safety-seeking behaviour → any behaviour that is performed in order to prevent a feared catastrophe from occurring and/or reduce its impact on the individual

  • E.g. a person with PD who is afraid of fainting may sit down immediately every time he feels dizzy.
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15
Q

Explain engagement in maladaptive cognitive strategies with regards to maintenace of maladaptive schemas & exaggerated threat appraisals

A
  • Thought suppression - anxiety disorders have tendency to suppress unwanted negative thoughts
  • Repetitive negative thinking - Heightened levels of repetitive negative thinking
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16
Q

How does thought suppression contribute to the maintenance of anxiety disorders?

A
  • Suppression successful in short term, but becomes less effective when employed over longer periods of time
  • thought suppression does appear to have direct negative effect on mood
  • Thought suppression can sustain/increase negative appraisals related to the suppressed thought
  • Individuals with anxiety disorders often appraise intrusive negative thoughts in catastrophic way, engaging in the suppression of intrusive negative thoughts should then = to maintenance of catastrophic appraisals
    e.g., “Worrying will drive me crazy” in GAD; “Thinking an aggressive thought makes it more likely that I will act on it” in OCD.
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17
Q

Explain rebound effect and thought suppression

A
  • Rebound effect: successful immediate suppression of thoughts often comes at the cost of a rebound later on
  • In absence of rebound effect, thought suppression has undesirable** side effects** that can contribute to the maintenance of anxiety disorders.
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18
Q

Explain repetitive negative thinking

A
  • Heightened levels of repetitive negative thinking
  • Worry and rumination maintain anxiety.
  • Engaging in repetitive negative thinking during negative mood impairs recovery from this very mood = maintenance of symptoms of anxiety & depression
  • Content of repetitive negative thinking often matches anxiety patients’ negative beliefs, which means that these beliefs are repeatedly rehearsed.
    Worry and rumination = increase in schema-congruent intrusive thoughts & memories
  • Worry and rumination: form of cognitive avoidance individuals engage in to avoid negative imagery, high levels of emotion or arousal, and/or decisive action.
  • E.g. GAD: excessive worrying
  • Example SAD: anticipatory processing (worry) before entering a social situation as well as post-event processing (rumination) afterwards
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19
Q

What are dysfunctional cognitive and behavioural coping strategies driven by?

A

Maladaptive beliefs

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20
Q

Give an example of the cognitive processes of OCD

A

Appraisals:
* “I didn’t turn off stove & house will burn down”
* “If I ignore this thought, I’ll be responsibele for the harm”

Beliefs/assumptions
* “Not preventing harm is as bad as causing harm”
* “Harmful events will happen unless I’m careful.

Information-processing biases
* Attentional bias towards threat
* Explicit memory bias

Safety-seeking behaviour
* Checking
* Seeking reassurance.

Dysfunctional cognitive strategies
* Thought supression

Additional processes
* Thought action fusion

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21
Q

Give an example of the cognitive processes of specific phobia

A

Appraisals:
* Dog will bite me
* I will scream uncontrollably

Beliefs/assumptions:
* Dogs are mean and dangerous
* If I don’t watch the spider, it will crawl into my clothes.

Information-processing biases
- Attentioanl bias toward personally relevant threat stimuli

Safety-seeking behaviour
- Stops walking when approached by a dog
- Keeps watching the spider

Dysfunctional cognitive strategies
* Thought suppression

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22
Q

Give an example of the cognitive processes of social phobia

A

Appraisals:
- People will look at me and notice that I’m trembling
- People will think I am incapable.

Beliefs/assumptions
* I am unlikeable
* I must not show any signs of weakness

Information processing biases
- Self-focused attention
- Attentional bias toward social threat
- Interpretation bias (e.g. facial expressions)
- Implicit memory bias

Safety seeking behaviour:
- Mentally rehearses what to say
- Avoids eye contact

Dysfunctional cognitive strategies
- Anticipatory processing (worry)
- Post-event processing (rumination)

Additional processes
- Negative mental imagery of self from an observer perspective.

23
Q

What are criticsms of the cognitive behavioural theory?

A
  • Difficulties in distinguishing safety behavior and justifiable coping or habits.
  • Smoking, for instance, might be a safety strategy when applied to calm oneself, but it might also be a habit or an addic- tive behavior.
  • On a methodological level, the heavy reliance on self-report has been criticized as it appears questionable whether the causal mechanisms involved in emotion and behavior are really open to introspection.
  • On a theoretical level, the assumption that controlled processes, such as conscious appraisal, are solely responsible for fear responses to situations has been challenged
24
Q

What is attentional bias (AB)?

A

Attentional bias (AB) toward disorder relevant threat stimuli.
* When threatening and neutral stimuli occur together, the attention of individuals suffering from AD (anxiety disorder) will likely be biased toward threat.
* Temporal unfolding of AB:
Early stages of threat processing: enhanced attention to threat;
Later stages of threat processing: attentional avoidance of threat.

25
Q

Explain the hypervigilance-avoidance pattern

A

phobics initially direct their attention towards fear-relevant stimuli, followed by avoidance that is thought to prevent objective evaluation and habituation;
→ pay attention to the threat, then quickly avoid it.

26
Q

What are the components of attention?

A

1. Alerting: involved in maintaining an appropriate sensitivity level to perceive and process relevant stimuli;
2. Orienting: involved in the selection of relevant information

3.Executive control:involved in conflict resolution and voluntary action control;

27
Q

How is attentional bias measured?

A
  • Dot-probe task / visual probe task = test used by cognitive psychologists to assess selective attention (measure how strongly your attention is drawn toward and held by specific types of stimuli);
  • Two images are presented simultaneously, one on the left side and one on the right side. Then, a dot appears either on the left or right, and participants identify the dot location. When the dot appears on the same side as threatening emotional information, responses are faster. When the dot appears on the other side, responses are slower.
28
Q

What are the treatment options for attentional bias?

A
  • Modified visual probe task: may also be used to reduce an already existent AB in anxiety patients;
  • CBT (cognitive behaviour therapy): strength as well as the pattern of pretreatment attentional bias (avoidant vs. vigilant) moderates the efficacy;
  • CBM (cognitive bias modification): primarily targets the later components of AB related to engagement difficulties.
29
Q

**How do these biases sustain anxiety disorders?

A
  • Memory bias?
30
Q

How is memory bias measured?

A
  • Stroop task;
  • Dot Probe task;
  • Implicit Association Task (IAT): measures reaction times in categorization process –> Press the left or right button depending on how you categorise it (pleasant/unpleasant).
  • Performance-based measures:
    Implicit Association Test;
    Affective Simon Task.
31
Q

What is interpretation bias?**

A

the tendency to inappropriately analyze ambiguous stimuli, scenarios and events.

32
Q

How is interpretational bias measured?

A
  • Modified lexical decision task
  • Homographs
  • Homophone
33
Q

What is the treatment for interpretational bias?

A

CBM-I: effects of CBM-I (interpretation modification) are generally larger than those of CBM-A (attention modification).

34
Q

Explain the role of interpretational bias in the persistence of anxiety

A
  • Enhanced IB may set people at risk for developing anxiety symptoms:
  • IB has prognostic value for anxiety at 1-year follow-up even after controlling for baseline anxiety;
  • Reducing IB is paralleled with a reduction in anxiety vulnerability;
  • Reducing negative IB and/or enhancing positive IB reduces anxiety symptoms in analogue
35
Q

What do cognitive behavioural models emphasise?

A
  • Cognitive behavioural models emphasise maintaining effects of safety behaviour in anxiety disorders.
  • Behavioural avoidance & safety-seeking strategies are common to all anxiety disorders & play an essential role for onset & maintenance of anxiety.
  • Safety behaviour can emerge to both external cues (situations, persons, activities) & internal cues (thoughts, emotions, memories) & usually employed to reduce experience of unpleasant feelings or risk of feared outcomes = important source of information about perceived focus of threat. Linked to functional impairment & could serve as an indicator of disorder severity.
  • Cognitive-behavioural theories of most anxiety disorders suggest that behavioural responses to anxiety might amplify and maintain threat perceptions, and need to be targeted and modified in therapy.
36
Q

What did Salkovskis introduce?

A

Salkovskis introduced safety-seeking behaviour in panic disorder (PD), dividing it into 3 categories:

  1. Avoidance of situations (e.g., avoiding crowded places or supermarkets);
  2. Escape from situation once anxiety symptoms arise;
  3. Subtle avoidance behaviours carried out during panic attacks in order to prevent a feared catastrophe (e.g., taking medication to avoid a heart attack, or sitting down).
37
Q

What are preventive safety behaviours?

A

Preventive safety behaviours are performed to prevent future bad emotional responses or increases in anxiety.

38
Q

What preventive strategies are included?

→ also described as emotional / experiential avoidance.

A
  • Situational avoidance;
  • Relying on safety signals (e.g., leaving home only when accompanied, relying on mobile phone);
  • Subtle avoidance behaviours (e.g., avoiding exciting activities or stimulating substances, avoiding eye contact, or avoiding touching things that might be contaminated as well as worrying, or excessive preparation).
39
Q

What are restorative safety behaviours?

A

Restorative safety behaviours are performed to stop the emotional experience from happening (leave a party or trying to control emotional response).

40
Q

What is the aim of restorative safety behaviours?

A

Those behaviours most often aim at either reducing:
* bodily symptoms related to anxiety (e.g., palpitations or shortness of breath, uneasiness); or,
* the perceived likeliness of feared consequences (e.g., dying, embarrassing oneself, bringing harm to oneself or others).

41
Q

What do restorative bheaviours include?

A
  • Escaping from situations or activities;
  • Attempts to control or suppress emotional responses (e.g., thought suppression, self-monitoring, taking medication);
  • Reassurance seeking (e.g., calling someone to calm down, asking whether everything is still okay);
  • Neutralising behaviours (e.g., washing when feeling contaminated).

image page 107!

42
Q

**What are the effects of safety behaviours?

A

Safety behaviours might directly amplify fear and anxiety;
* Continuous self-monitoring increased their vigilance to harmless fluctuations in body symptoms that were, in turn, often more perceived;
* Increased self-awareness in feared situations = also core process in social phobia;
Safety behaviours might reduce the experience of anxiety in situation but facilitate its recurrence and persistence over time (negative reinforcement);
Safety behaviours might contribute to the development of anxiety.
Threat overestimation might stimulate the use of inappropriate safety behaviour that, in turn, contributes to the development of pathological fears and anxiety.
Safety behaviour is maintained through negative reinforcement, since restorative strategies, such as neutralising, first reduce anxiety, but lead to stronger urges to neutralize in subsequent trials.
Safety behaviour that is most often linked to specific phobia is escape.

43
Q

How can we remove safety behaviours?

A
  • Exposure therapy in small increments so e.g. take safety behaviours away step by step?
  • E.g. in an elevator every time a bit longer.
  • Some authors say get rid of all safety behaviours but others say some safety behaviours may be beneficial, don’t need to get rid of it.
  • exposure therapy– facing fear head on
  • changing the association you have with the fear
  • if you don’t perform the safety behaviour, you will get positively reinforced, and if you do you are punished negatively
  • intensity of removing safety behaviours
  • little by little
  • some authors say to get rid of all safety behaviours, others say some may be beneficial or a healthy crutch
  • safety behaviours are a distraction so get rid of them all, because if not they will come back more easily (maladaptive pathway still exists)
44
Q

What is information processing theory?

A

framework used by cognitive psychologists to explain and describe mental processes (based on the idea that humans process the information they receive, rather than merely responding to stimuli).

45
Q

What are the most prominent cognitive biases in anxiety disorders?

A
  • Attentional bias;
  • Interpretation bias;
  • Memory bias;
  • Covariation bias;
  • Reasoning bias.
46
Q

What is covariation bias (CB)?

A

Covariation bias (CB) = anxiety-disordered individuals may tend to overestimate the contingency between concern-relevant stimuli and aversive outcomes (e.g. heart palpitations are commonly not followed by a heart attack).

47
Q

What is reasoning bias (RB)?

A

individuals tend to search for belief-confirming information and that their habitual reasoning pattern is biased in a way that confirms rather than falsifies prior beliefs.

48
Q

What is the relation between information processing thoery and the cogntivie theory?

A

rise of cognitive models implying that emotional disorders critically depend on the existence of maladaptive cognitive structures in memory. These so-called schemas are assumed to automatically influence all stages of individuals’ information processing.
Domains:
* Attention bias - separate question
* Interpretation - separate question
* Memory – question sustain anxiety disorder

49
Q

Explain schemas with regards to concept of cognitive theory

A
  • Threat appraisals thought to be due to cognitive schemas
  • Cognitive schemas often described in form of beliefs & assumptions/rules
  • Cognitive schemas in anxiety: more negative, more rigid & less flexible.
50
Q

What is cognitive schema?

A

Cognitive schemas → underlying cognitive structures that have developed in response to earlier experiences & that can be activated by matching triggers.

51
Q

What are assumptions/rules with regards to cognitive schemas?

A

Assumptions/rules = conditional (e.g., “If others see that I am anxious, they will think I am weak”; “If my heart is racing and I am trembling, I will get a heart attack”)

52
Q

What are beliefs with regards to cognitive schemas?

A

Beliefs = global & unconditional in nature (e.g., “I am vulnerable”; “I am worthless”).

53
Q

What cues can safety behaviour eemerge to and what is safety behaviour usually used for?

A
  • Safety behaviour can emerge to external (situations, persons, activities) & internal (thoughts, emotions, memories) cues
  • usually used to reduce experience of unpleasant feelings or risk of feared outcomes

Anxiety & related disorders (5 decks)

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