THE COGNITIVE MODEL OF ANXIETY

Anxiety is the most common of psychiatric complaints. Prolonged anxiety problems can disrupt work, interpersonal relationships, and sleep; when anxiety reaches the heights of panic, it can be debilitating. Thankfully, anxiety is quite treatable, and cognitive therapy for anxiety is one of the methods with considerable research support.

Like depression, it is useful to break anxiety down into its symptom categories such that the tangible aspects can be identified.  You will discover that like the cognitive behavioral approach to depression, moderating anxiety involves disallowing the symptoms that perpetuate the state.

The emotional component of anxiety is fear. It is by anyone's definition a painful urgent emotion, like some uninvited high voltage current running through you. Nervousness is used to describe low level anxious mood, and at the opposite extreme, panic, a profound blast of anxious affect. The physical symptoms of anxiety are myriad; shortness of breath, rapid heart rate, shakiness, dizziness, unsteadiness, numbness and tingling, lightheadedness, feelings of choking, sweating. Most people reckon the physical symptoms to be the most distressing part of the anxiety experience. In terms of cognitive symptoms, anxiety strongly influences attention such that one's focus becomes narrowly directed toward the danger at hand. With some forms of anxiety (e.g. panic disorder, performance anxiety) attention becomes self-focused. With regard to memory retrieval, anxiety creates significant blocking of non-threat related information; you just can't think of anything but what you're anxious about! When anxious, one's automatic thoughts and mental images tend to be catastrophic; that is, there is an exaggeration of the dangerousness of the situation and a simultaneous underestimate of one's control over that danger.

So, to summarize, when the anxiety experience is activated, there is an unsettling urgent emotion present, intense physical involvement the body is alerted in a way that is impossible to ignore. Attention becomes narrowly focused on whatever the source of the anxiety is to the extent that other information becomes inaccessible. Plus, the disasterousness of the situation is amplified and control resources are minimized in one's mind. This quite rapid activation of symptoms has one behavioralpurpose, Flight. And it is without a doubt the most important mechanism, in terms of survival, that we have in the circuitry of our brains. If anxiety didn't happen in the face of danger, we'd all perish for sure. Anxiety alerts us to danger and makes us more likely to escape from it. However, some people experience an inappropriate level of anxiety given the dangerousness of the situation and/or have enduring anxiety despite a relatively safe environment. Anxiety problems can be described as false alarms that are too frequent, too profound, and or too prolonged.

Anxiety problems are self-perpetuating, mostly by virtue of cognitive distortions and the overuse of flight/avoidance strategies. Consider an example. Joe quit his job due to severe anxiety. He's been out of work for a month. A friend orchestrated a job interview for Joe tomorrow, and the night before, he is catastrophizing and therefore experiencing a considerable amount of anxious mood and physical symptoms. The more anxious Joe gets, the more catastrophic he thinks, until he can't stand it any more and elects to cancel the interview. The canceling of the interview brings about an immediate reduction of anxiety, and therefore, the next time Joe is offered an interview, he will not only be likely to catastrophize and experience considerable anxiety, but he will also be strongly compelled to cancel the interview. With several such scenarios, Joe becomes stuck in an anxiety/avoidance cycle that is very difficult to get out of. 

Treatments for anxiety focus on each of the four symptom groups:  

Emotional: Medicines target the emotional symptoms of anxiety directly, for example, benzodiazepines influence the neurotransmitters responsible for anxious mood (as well as the physical symptoms), as do some of the Serotonin antidepressants. A sound pharmacological regime is often a necessary part of anxious individuals' treatment. However, MDS are always mindful not to have their patients use sedating medications as the sole means of dealing with anxiety, as they may come to depend exclusively on the medication, to the point in which medications are overused, or as-needed anxiolytic medicating becomes an avoidant strategy in and of itself.  

Physical: It is literally impossible to be anxious and relaxed at the same time. Therefore, skills for promoting relaxation are very powerful in reducing anxiety. Progressive Muscle Relaxation is a method designed to teach you how to recognize involuntary muscle tension and relax muscle groups. The diaphragmatic breathing technique is an exercise that reduces the rate and increases the depth of breathing to promote relaxation. With considerable practice, anxious individuals can learn to slow down their breathing during bouts of anxiety. Visualization techniques are aimed at helping people bring about a relaxed physical state by conjuring up vivid and soothing experiences and fantasies.

Cognitive: Cognitive skills for managing anxiety involve distractionand decatastrophizing. Distraction is a very powerful means of reducing intense anxiety and panic. When one is consumed with a high level of anxiety, it is very hard to recognize and challenge distorted thoughts. However, if panic-stricken people can "get out of their heads" for a few minutes by focusing intensely and exclusively on some outside stimulus (while at the same time using the diaphragmatic breathing method) anxiety will diminish, often to a level where individuals can reason with themselves.

COGNITIVE EXPOSURE.This method, which involves the consideration of worst case scenarios, is useful for ruminative situations in which there is a chance of a moderately negative outcome. It is not advocated for situations in which there is a remote chance of something extremely catastrophic, such as death, terminal illness, prison time, living on the street, as this technique will only lead to increased rumination and catastrophizing. Some appropriate events for cognitive exposure would be, returning to work, being assertive with your boss, dropping a class, a job interview. Cognitive exposure involves, first, thinking in a very vivid way about the worst potential outcome, then walking through the steps as to what you'd really do about it if it actually happened. Though this technique might sound like ordinary worrying, it is quite different. Worrying or ruminating is a self-protective strategy we engage in to prevent worst case scenarios. With cognitive exposure, you are actually placing yourself in the situation. In your mind, there is no way you can prevent it, because it has already happened. Anxiety reduction comes from mentally walking through the steps as to what you would realistically do and discovering that, though undesirable, the outcome wouldn't kill you.

For example, consider a young man returning to a stressful job, the worst case scenario being, "having to quit". Imagining this actually occurring puts the fellow in the position such that he must do something. The following responses might come into his mind; "I'd cry…"I'd call friends for support"…"I'd probably receive support"…"In several days I'll start looking for another job (reminded of his ability to always find work and good interview skills)"…"I'd check out work in part of town closer to home"…"I'd eventually get job, possibly a less stressful job." 

This exercise almost invariably leads to the realization of many, many safety nets and methods of coping, such that worst case scenario, though negative and certainly not desirable, would not be devastating. In some instances, such as the above, worst case scenarios can even yield positive outcomes.

The next step is to conjure up vividly the best case scenario. It is important to focus on worst case first, as best case will seems absurd until you've convinced yourself you can handle the worst case. Using the above example, the best case scenario might be returning to work and finding things to be considerably less stressful due to changes initiated by his boss and better stress management skills.

After imaging both worst and best potential outcomes, the logical conclusion is that all outcomes in-between could be managed; however, as a third step, entertaining one or two realistic case scenariosplaces you in a balanced state of mind. Again, it isn't until the most terrible outcome is "exorcised" that the more likely realistic outcomes can be entertained in a believable way. Using the example, a realistic outcome might be returning to find things a bit less stressful due to increased ability to manage stress and approaching the first week on the job a trial period during which other job opportunities will be investigated so that if things end up being overwhelming, a smooth transition can be made.

REDUCING THE GAP. Above, catastrophic thinking was described as an exaggeration of danger and an underestimate of one's control over that danger.

When the conceptualization of control is in line with that of danger, that is, when there is no space between the two continua, then anxiety is absent. For example, imagine you're downtown, and there is an intoxicated lecher barreling down the sidewalk toward you with a nasty scowl on his face and a crowbar in his hand. Now, most of us would deem that a pretty dangerous event. However, it's the middle of the day, and there's three muscle bound vigilantes walking right in front of you, plus a row of open doors parallel to the sidewalk leading into the police station plus you are a triple black belt in Tai Quan Do, then the control one has is pretty much in line with the dangerousness of the event. Now, if we change the time of day to three a.m. , put closed signs on all the police station doors, a cast on your leg and a pair of crutches. Now we have a considerably more dangerous situation with much less control over it, and consequently some pretty intense anxiety.

The above conceptualization suggests that the level of anxiety is less a function of specific dangers or controls, and more the "distance" between these two conceptualizations that will determine the amount of anxiety. The greater the gap between our conceptualization of danger and our conceptualization of control, the greater the anxiety. Moving away from the example of menacing thugs and crutches, we could imagine the danger of a job interview, conceptualized as hostile interviewers with impossible questions, and our controlover the interview as next to nil, in that there will be an inability to respond, anxiety, tearfulness, possible fainting. Here, though the actual situation would seem by most to be less dangerous, the gap could result in a level of anxiety commensurate with the example involving thugs and crutches.

Reducing the gap involves, first, translating your anxious mindset into beliefs about   danger and beliefs about control, then performing a test of evidence on each of those beliefs to determine whether they are biased. The decatastrophizing form that follows this article offers an opportunity to begin challenging catastrophic thoughts.

Behavioral symptoms:  Countering avoidance is believed to be the most powerful means of reducing anxiety problems. Avoidance reduces anxiety in the short term, but it actually makes for more anxiety in the long term, as avoidance breeds more avoidance and it becomes increasingly more anxiety provoking to counter avoidance. Using the example of the young fellow returning to work, if he catastrophizes returning to the extent that his anxiety is extreme, he may choose to postpone it. This will decrease his anxiety and make it even harder to return the next day, because not only will he have increased anxiety just considering it, but he will have a strong drive to postpone again, given that the previous postponement resulted in a decrease in anxiety. Exposureinvolves placing oneself in the avoided situation, despite the anxiety, and staying there until the anxiety ebbs completely. With most forms of anxiety, a hierarchy of exposure is established; i.e. the person gradually exposes himself to what has been avoided, starting with a level that evokes a minimum of anxiety, and increasing the level of exposure as each level is successfully extinguished, while simultaneously utilizing relaxation exercises and decatastrophizing techniques.

This method of exposing anxious individuals gradually is called systematic desensitizationand was originally used to help people with phobias. For example, a snake phobic would be exposed first to photographs of snakes, and asked to look at them while using relaxation and decatastrophizing skills until the photos no longer cause anxiety. Then the person would be exposed to a realistic rubber snake, here touching it, holding it, while using relaxation and decatastrophizing skills until the anxiety diminishes completely. The next exposure step might involve a live snake in a locked aquarium, and several more steps all the way up to holding a live harmless snake. Systematic desensitization as applied to the young fellow returning to work might have as an initial step driving around the parking lot of his job on a Sunday, followed by talking to a colleague on the phone, and then visiting work prior to returning, starting part time, eventually back to full time employment.

One of the reasons anxiety is so treatable is that there are so many potentially effective ways to intervene. Though everyone is different as to which methods are most effective, it is recommended that all the aforementioned skills are practiced.   Unlike skills for managing depression, some of the cognitive behavioral techniques designed to help you reduce anxiety necessarily cause an increase in anxiety prior to a lasting reduction. It is important to continue with the techniques despite the temporary increase, as it is a necessary part of the recovery from anxiety. Using an exercise analogy, when someone who is out of shape begins to work out, it is typically excruciating, and there is often strong motivation to abandon the regime. If he or she keeps with it, the workouts become easier, enjoyable even, as he or she becomes more toned and attractive.   

Author: Robert Westermeyer, Ph.D.