Cognitive Behavioural Therapy for Anxiety Disorders

In this series of blog posts I am going to look at Cognitive Behavioural Therapy (CBT) formulations for a range of diagnoses. In the current blog I will look at CBT formulation for anxiety.

CBT formulation explores factors that make individuals more vulnerable to developing anxiety problems (predisposing factors), factors that may trigger an episode of anxiety (precipitating factors), and factors that increase the likelihood of the problem continuing (perpetuating factors). Events that occur during childhood may increase vulnerability to developing an anxiety problem. For example, overprotective or critical parent styles, neurodevelopmental difficulties, physical illness or bereavements. These events shape our ‘core beliefs’. Core beliefs are our beliefs about others, the world, and ourselves, which are deeply ingrained. Our core beliefs will lead us to hold certain rules or assumptions about how things work. We then develop behaviours or coping strategies based on these assumptions. These will be activated throughout situations in our lives.

Here is an example of how this might look for someone with a diagnosis of generalized anxiety disorder (GAD):

Core Belief: I am helpless. I cannot cope. Others will ridicule me. The world is dangerous.

Assumptions/Rules: If something goes wrong I will not be able to deal with it. I cannot cope.

Coping Strategies: Avoidance.

Situation: Sam is asked to give a presentation at work.

Automatic thought: I can’t do it. My boss will realize that I’m useless and she will fire me.

Emotion: Worried about negative appraisal and possibility of getting fired. Upset.

Behaviour: Fabricate excuse or call in sick.

The presentation was the precipitating factor. However, avoiding the presentation means that the worry never goes away and therefore avoidance actually serves to keep the problem going. Therefore, avoidance is a perpetuating factor. Sam has learned that avoiding difficult situations is an effective way of reducing his anxiety, and has also missed an opportunity to see that his worry was unsubstantiated.

Consider if Sam had done this presentation and received positive feedback from his boss and colleagues. This would have removed the concern of getting fired and provided contrary evidence to his belief of being useless. This would make him less likely to fear presentations in the future as he now has had a positive experience. Of course, it is unlikely his anxiety would completely diminish after one presentation. However we would expect that if he were to present regularly his anxiety would reduce substantially.

Within CBT formulations we also look at protective factors, which are positive things in the person’s life that may help them to overcome their difficulties. For example, positive relationships, adaptive coping strategies and general interests.

Here is an example of a CBT formulation for someone with a diagnosis of obsessive-compulsive disorder (OCD):

Core Belief: My thoughts are powerful. I must not think bad things.

Assumptions/Rules: If I can control my thoughts then I will be safe. If something bad happens because of my thoughts then it is my responsibility.

Coping Strategies: Compulsive behaviours, which act to neutralize intrusive thoughts.

Situation: Rita came into contact with dirt while cleaning her house.

Automatic thought: What if I fall ill or get an infection? What if I make someone else ill?

Emotion: Worried about getting sick or making others sick.

Behaviour: Washing hands several times.

Other routines such as checking that environments are completely clean in the future.

Dirt was the precipitating factor that led Rita to experience feelings of anxiety. To reduce this anxiety Rita began to wash her hands repeatedly until she felt calmer. This compulsive/safety behavior is a perpetuating factor, as Rita will continue to do this in the future, as she has learned that this is an effective way of reducing her anxiety. However, this is blocking her from learning that no-one will become sick as a result of dirt in the environment, or that if they did become ill that this would be minimal. In these situations it would be helpful for Rita to be exposed to dirt so that she learns that these situations are manageable and that nothing awful happens as a result. Rita would also need to engage in response prevention, which means that she would not engage in her compulsive behaviour. Engagement in compulsive behaviours during exposure work is counterproductive, as this would lead Rita to believe that her rituals are keeping her safe. By preventing herself from engaging in compulsive behaviours Rita learns other ways to manage her anxiety and realizes that it is not the compulsive behaviour that is protecting her.

In my next blog post I will look at CBT formulation for depression.

The International Psychology Clinic

The International Psychology Clinic