Well, CBT addresses panic disorder effectively:
"Panic disorder is the experiencing of feelings of extreme fear which strike unexpectedly for no apparent reason. It is caused by the misinterpretation of physical sensations the person is experiencing at the onset of the panic attack. The sensation of panic is accompanied by intense physical symptoms of discomfort. Sufferers also experience anticipatory anxiety, worrying about their next panic attack, and avoiding situations that are likely to cause its onset (Gross & McIlveen 2005, p.63). CBT addresses the client’s misinterpretation that benign or harmless events predict something catastrophic happening or being about to happen (Beck 1995, p.297, from Beck 1987)."
WORKING WITH ANXIETY
Anxiety disorder is contained in the idea that it is an individual’s overestimation of the risk in a situation and the underestimation of their capacity to deal with it - the distance between these two estimations is a measure of the degree of anxiety being felt .
Anxiety is a naturally-evolved response to the threat of danger and keeps humans safe in a world that contains many risks. Anxiety becomes anxiety disorder when someone’s anxiety is disproportionate to the threat being faced and is routinely disrupting the person’s life.
Intense worry or fear characterises anxiety. It manifests as difficulties in concentration, irrational thinking, confusion and tearfulness, feelings of hopelessness, and loss of self-esteem and confidence. These psychological symptoms are accompanied by physical symptoms which include muscle tension, a dry mouth, shortness of breath, palpitations and a racing heart, tightness or pain in the chest, nausea and sweating. Anxiety will also frequently bring about stomach upsets and headaches. The physical symptoms of anxiety can themselves cause increased levels of anxiety in the sufferer, particularly in Panic Disorder.
During anxiety there is a strong belief that the object of the anxiety is real, irrespective of this rationally being the case. This belief then affects behaviour, emotions and physiology. A typical response to anxiety is avoidance. This is a main factor in maintaining an individual’s anxiety. Although it seems reasonable to keep ‘safe’ by avoiding the cause of the anxiety, this strategy causes it to remain unresolved. Overcoming anxiety involves understanding its causes, and through behavioural experiments, gradually testing out whether the individual’s perception of the cause is reasonable or accurate.
It is important to note that depression is differentiated from anxiety by the global sense of ‘hopelessness’ which characterises depression. Research (Beck et al, 2006) shows that anxious patients consistently have a significantly lower measure of hopelessness about resolving life problems than do depressed patients.
Types of anxiety disorder
There are three main types of anxiety disorder: generalised anxiety disorder (GAD), panic disorder (PD), and phobic disorder. In addition, a further two disorders are included within DSM-IV as anxiety disorders: obsessive-compulsive disorder (OCD), the presence of persistent and unwanted thoughts, together with the compulsion to act out ritualistic behaviour, and post-traumatic stress disorder (PTSD), the repetitive and uncontrolled mental re-experiencing of stressful emotional states.
Generalised anxiety disorder is characterised by exaggerated and worrisome thoughts about everyday life-events. Not linked to specific situations, the sufferer will be unable to pinpoint the exact causes of anxiousness. CBT responds to generalised anxiety by socialising the client into more realistic assessments of the threats being anticipated, and reinforcing their ability to cope with situations they see as threatening (Beck 1995, p.297, from Beck & Emery, 1985).
Panic disorder is the experiencing of feelings of extreme fear which strike unexpectedly for no apparent reason. It is caused by the misinterpretation of physical sensations the person is experiencing at the onset of the panic attack. The sensation of panic is accompanied by intense physical symptoms of discomfort. Sufferers also experience anticipatory anxiety, worrying about their next panic attack, and avoiding situations that are likely to cause its onset (Gross & McIlveen 2005, p.63). CBT addresses the client’s misinterpretation that benign or harmless events predict something catastrophic happening or being about to happen (Beck 1995, p.297, from Beck 1987).
Phobic disorder relates to extreme and irrational fears about particular objects or situations. Avoidance of the feared object or situation causes dysfunction in the sufferer’s life. Phobia is different from a milder fear or dislike of something. The phobia is irrational because the sufferer realises that the object of fear is generally harmless, but nevertheless they still experience fear (Gross 2005, p.776). Agoraphobia is fear of being unable to escape from an unsafe situation. Social phobia is an excessive fear of being amongst other people. Specific phobia relates to a fear of particular objects or situations such as spiders or being in the darkness.
Approaches to treating anxiety disorder
In addition to CBT, other therapeutic responses to anxiety include treatment within the medical, psychodynamic and behavioural models of illness. However the aim of all responses is to manage rather than banish anxiety (Grant et al, 2004). Common to all models of treatment is the need to treat comorbidity in the client, i.e. other diagnosed disorders such as an addiction or depression.
The medical model of health is based on the idea that mental illness has physical causes and so should be treated with physical responses (Gross & McIlveen, 2005 p.11). Accordingly, the medical response implies the use of pharmaceutical medication to treat anxiety, typically SSRI-type anti-depressants and/or ‘beta-blockers’.
The psychodynamic model of health describes mental health problems as the result of unconscious ‘defence mechanisms’ stemming from the client’s historical experiences. These defence mechanisms protect the conscious mind from intolerable anxiety. However, this protective measure becomes unhelpful when the cause of the distress is no longer present, and the person consequently becomes ‘ill’. The psychodynamic psychotherapist seeks to instil cognitive and emotional insight in the client about how he or she thinks, feels and behaves through the re-enactment of elements of the client’s past, using the therapeutic relationship between therapist and client as a vehicle for this work (Geraghty, 2004). (!)
The behavioural model of health infers that illness is ‘learnt’, and therefore it can be ‘unlearnt’. In the case of anxiety, treatment is centred on learning how to control symptoms of distress through relaxation, reducing avoidance of anxiety-provoking situations through graded exposure to them, and the building of confidence by re-engagement in “pleasurable and rewarding activities” (Butler et al, 1991).
CBT and anxiety
The cognitive model of health, developed by Aaron Beck in the 1960’s, is founded on the idea that distressing feelings and unhelpful or inappropriate behaviours stem from a distorted interpretation of an individual’s thoughts – ‘The individual’s ‘emotional reactions are essentially a function of how [he/she] construes the world.’ (Gross, 2005, p. 827, from Beck, 1967).
Cognitive Behavioural Therapy therefore ‘reframes’ the thoughts influencing a person’s emotions and behaviour by challenging the automatic assumptions and attitudes the client holds about self, others and the world at large. Negative automatic thoughts maintain distorted thinking by preventing the opportunity to experience alternative interpretations about the issue(s) causing distress. An accompanying lack of self-confidence also reduces belief in the ability to carry out activities successfully. The function of the therapist is to interrupt this negative and self-perpetuating circle of symptoms and behaviours.
The ‘cognitive’ aspect of the therapeutic response is to recognise that anxiety can be controlled by identifying anxious thoughts and then seeking more realistic and helpful alternatives to them. The ‘behavioural’ element in the therapy is the use of experiments that behaviourally test out alternative interpretations of thinking patterns. The outcomes of these experiments are assessed (by the client) in terms of reduction of symptoms and levels of distress. In this way the CBT client progressively modifies their thinking errors and behaviours, ameliorating the distress they experience.
In the therapy these behavioural experiments or interventions will usually be set as ‘homework’ for the client to carry out in the periods in between the therapy sessions. In addition, the use of assessment tools such as the Beck Anxiety Inventory gives indications of change during the course of the therapy, as well as highlighting aspects of the client’s problems that may particularly need addressing. After an appropriate period of treatment the client is able to reduce his/her level of anxiety, avoiding excessive anxiety itself, rather than (as previously) avoiding its causes.
An assessment of CBT as an effective response to anxiety
There is a body of clinical research evidence suggesting that CBT is a more effective response to anxiety than either pharmacological treatment (NICE, 2004, Clinical guideline 22, Section 1.7.1) or standard behavioural therapy.
An example is the Butler study ((Butler et al, 1991)) carried out at Oxford University in the early 1990’s, in which it was found that after treatment twice the proportion of subjects in a CBT group achieved a particular target level on anxiety scales, compared to a parallel Behavioural Therapy (BT) group (32% against 16% respectively). Furthermore, at a subsequent six-month assessment, the proportions meeting the target anxiety scale criteria were 42% and 5% respectively for the CBT and BT groups. These results indicate that cognitive-behavioural therapy is more effective than behavioural therapy as a treatment for anxiety disorder, but also, importantly, that the therapeutic effect of cognitive-behavioural therapy is more enduring.
Anxiety is a natural response to danger or the threat of danger, but excessive anxiety that leads to dysfunction in an individual’s life is an anxiety disorder. Psychological symptoms of anxiety are accompanied by physical symptoms which may themselves cause increased levels of anxiety. The aim of the therapeutic response to anxiety disorder is to manage rather than banish the individual’s anxiety. The cognitive-behavioural model of health holds that distressing feelings and unhelpful behaviours stem from distorted interpretations of the individual’s thoughts. The cognitive-behavioural response to anxiety disorder recognises that anxiety can be controlled by seeking more realistic interpretations to anxious thoughts, which are then validated through behavioural experiments, leading to a reduction of symptoms and distress.
Assignment bibliography and references
Beck, A.T. (1987). Cognitive Model of Depression. Journal of Cognitive Psychotherapy: An International Quarterly, 1, 5-37.
Beck, A.T., Brown, G., Riskind, J.H., Steer, R.A. & Wenzel, A. (2006). Specificity of Hopelessness about Resolving Life Problems: Another Test of the Cognitive Model of Depression. Journal of Cognitive Therapy and Research, 30, 773-781.
Beck, A.T. & Emery, G. (1985). Anxiety Disorders and Phobias: A Cognitive Perspective. New York: Basic Books.
Beck, J.S. (1995). Cognitive Therapy - Basics and Beyond. New York: The Guilford Press.
Butler, G., Fennell, M., Robson, D. & Gelder, M. (1991). Comparison of behaviour therapy and cognitive-behaviour therapy in the treatment of generalised anxiety disorder. Journal of Consulting and Clinical Psychology, 59, 167-175.
DSM-IV. (1994). American Psychiatric Association - The Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition.
Grant, A., Mills, J., Mulhern, R. & Short, N. (2004). Cognitive Behavioural Therapy In Mental Health Care . London: Sage Publications Limited.
Gross, R. (2005). Psychology – The Science of Mind and Behaviour. London: Hodder Arnold.
Gross, R. & McIlveen, R. (2005). Abnormal Psychology. London: Hodder & Stoughton Educational.
NICE. (2004). National Institute for Clinical Health and Excellence. Anxiety - Management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. Clinical guideline 22. December 2004.
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