Understanding Anxiety Disorders

Anxiety

• Anxiety can be described as a basic emotion, a personality dimension, or a psychological disorder

Identifying Anxiety

• Anxiety is a normal response to danger or thoughts
• Anxiety has cognitive, behavioral, and physiological subsystems
• Cognitively, anxiety involves worry, racing thoughts, hypervigilance, and tunnel vision
• Behaviorally, anxiety involves avoidance, fleeing, and freezing
• Physiologically, anxiety involves increased blood pressure, heart rate, and sweating

Anxiety as a Disorder

• Anxiety is considered a disorder when it interferes with functioning, is prolonged/excessive for about 6 months, and impairs quality of life
• The DSM 5 has three chapters of anxiety disorders: Anxiety disorders, Obsessive Compulsive Disorder (OCD) and related disorders, and Trauma and Stress related
• Anxiety disorders include: Separation anxiety, Selective mutism, Specific phobia, Social anxiety disorder, Panic attack, Agoraphobia, Generalized anxiety disorder, Substance induced anxiety, Anxiety due to medical condition, and Unspecified anxiety disorder
• OCD & Related Disorders include: Obsessive Compulsive Disorder, Body Dysmorphic Disorder, Hoarding, Trichotillomania (hair pulling), Excoriation (skin picking), Substance induced OCD, OCD related medical condition, Other specified OCD, and Unspecified OCD
• Trauma and Stress Disorders include: Reactive attachment disorder, Disinhibited social engagement disorder, Post traumatic stress disorder (PTSD), Acute stress disorder (ASD), Adjustment disorder, Other specified trauma and stressor disorder, and Unspecified trauma and stressor disorder

Cognitive Theory (Beck, 1976)

• Cognitive Theory suggests that dysfunction occurs from how individuals interpret events, which influences behaviors important in maintaining emotional problems
• Thoughts influence reactions, and this is impacted by cognition
• Cognition is comprised of Automatic thoughts, Underlying Assumptions, and Cognitive Schemas
• Negative Automatic Thoughts (NATs) are verbal, image-based, involuntary, and rapid and most people are or can be made aware of them
• Unhelpful thinking styles (cognitive distortions) include overgeneralization, magnification or minimization, mind reading, and arbitrary inference
• Schemas, i.e. core beliefs, are underlying beliefs and assumptions about self and the world based on experience and used to organize and interpret new information
• Schemas are interpreted as absolute truths and are often learned early in life but can develop or change later in life

Panic Disorder (Example)

• Clark's (1986) panic model suggests that panic results from catastrophic misinterpretation (CM) of internal sensations
• A trigger stimulus can be internal or external which starts a cycle of perceived threat, apprehension, body sensations, and catastrophic interpretation of sensations
• Therapist challenges belief in CM by corrective information and Socratic method
• Behavioral experiments involve hyperventilation provocation

Efficacy and Issues with CBT

• Cognitive Behavioral Therapy (CBT) is the recommended treatment per NICE Guidelines for treating psychological disorders
• CBT Effectiveness varies and shows approximately 50% recovery in Generalized Anxiety Disorder (GAD), and Major Depressive Disorder (MDD)
• CBT provides higher recovery in panic and social phobias
• Issues: relapse rates are a problem, especially in depression
• Some anxiety disorders are harder to treat using CBT, such as OCD and GAD
• Springer et al (2018) performed meta-analysis of GAD outcomes
• Remission rates apply for individuals who no longer have a diagnosis after treatment
• CBT is effective as exposure therapy for OCD (Fisher & Wells, 2005)
• Although the majority of patients improve over the course of CBT treatment, the majority are left with significant symptoms at the end of treatment

Metacognitive Therapy (MCT)

• Metacognitive Therapy MCT (Wells, 2009)
• Metacognitive Therapy is theory driven (Self Regulatory Executive Function (S-REF) Model) systematic development and estimation
• Metacognitive Therapy overcomes theoretical limitations of CBT
• Metacognitive Therapy is developed with scientifically tested techniques and driven by a-priori theory
• Key Point: most people have negative thoughts but do not develop anxiety disorder, why?

Principles of MCT

• "Thoughts don't matter but your response to them does" (Wells, 2009, p. 1)
• Psychological distress is maintained by a style of thinking (the Cognitive attentional syndrome (CAS))
• CAS includes worry, dwelling (rumination), threat monitoring, unhelpful coping strategies (thought suppression)
• CAS is driven by a set of beliefs which equate to metacognitive beliefs
• Metacognitive beliefs are beliefs about thinking

Positive & Negative Metacognitive Beliefs

• Negative Metacognitive Beliefs include Uncontrollability/dangerousness of worry, "I cannot control my worrying", and "Worrying will harm my mind/body"
• Positive Meta Cognitive Beliefs consist of the Benefits/usefulness of worrying, "Worrying helps me cope" and "If I worry I'll be prepared"
• Negative metacognitive beliefs (NMB) regarding uncontrollability and danger are seen across psychological disorders
• uncontrollability & danger has a strong link to psychological distress
• NMB is positively associated with increased anxiety and depression across physical illnesses even after controlling for age, gender, disease factors and cognition

Model of GAD

• Characteristics of GAD consist of Uncontrollable worry
• Type 1 worry is worry about social, self and the world
• Type 1 worry alone is not sufficient to cause GAD
• GAD develops when negative metacognitive beliefs are activated
• Type 2 worry (meta-worry) = patient worry about the fact that they are worrying
• Control processes that maintain psychological distress, prolong maladaptive thinking, and maintain maladaptive metacognition
• More thinking
• Suppression of trigger thoughts
• Reassurance seeking
• Avoidance

MCT Steps & Efficacy

• Metacognitive Therapy for GAD steps are: Generate/Share case formulation and then Challenge uncontrollability and other meta beliefs by showing patients that their belief is controllable
• To challenge dangers, a therapy must try to lose control of worry
• To challenge positive meta beliefs, therapists use worry modulation experiments
• MCT has been evaluated systematically from case studies, to pilot studies, uncontrolled trials, and randomized controlled evaluations
• Normann & Morina (2018) conducted the review & meta-analysis of MCT efficacy
• In efficacy trials, 25 studies of MCT - 15 were controlled
• MCT is significantly more effective than waitlist (Hedges' g = 2.06)
• MCT is significantly more effective than CBT (Hedges' g = 0.69) and follow-up (0.37)
• Results suggest that MCT is highly effective in treating disorders of anxiety and depression and may be superior to CBT