L2 - Models of Anxiety Flashcards
Learning Objectives
- Be able to describe the theories from the literature or the lecture
> if it has own heading in literature, we should know how to describe it - Reflect on the use of these theories or models for clinical practice
- Evaluate the relationships between the components of the models
- Use (aspects of) the models to explain clinical phenomena
Models - General Notes
- often clinicians complain that models don’t explain well the disorder, and they don’t represent accurately what the disorders look like in real life
- many models were created by researchers, other ones by therapists
> most useful ones in clinical practice are the ones created by therapists
Model 1. The Cognitive Triangle and CBT
- the way you think affects the way you feel, and the way you behave
> e.g. if I think I am a loser, it will make me feel sad and behave differently - everything is a cycle and a feedback
> e.g. if I think people dislike me, I will behave like they do and they will start disliking me - if we change what people think→ we can change how they feel and how they behave (and vice versa)
! still at the base of CBT (simple but with a lot of true value)
Why was this model revolutionary?
- before this time, there only was Freudian psychoanalysis, which was attributing all reasons to associations, repressed sexual behaviors, fixations, …
- now, maybe depression comes from thoughts/behaviors/feelings
what is the difference between Beck and Ellis?
- Beck dove into research into what it means to “think”
- he evolved model and made it more complex
- gave lots of evidence to the field (lots of research)
> is it true that thinking affects feelings?
Anxiety vs Fear
- Fear→ stress response from immediate danger
- Anxiety→ stress response just from your thoughts
> more lingering, thinking about what could happen
> keep thinking about all scenarios
> keep ruminating, generalize thinking
New vs Old brain
Old Brain
- sensory perceptions
- motives, emotions and behaviours
- fast, here, now
New Brain
- think about what can happen in the future/past
- feeds back into old brain (e.g. back to stress response)
Verbal/abstract vs Sensory/perceptual
- these are the two general ways of thinking that we have
- they feedback onto each other
- this keeps us ruminating/worrying about things
Cognition - model
- Content vs Processes
> Content of cognitions:
→ what we think
→ e.g. “I am a loser”, “I want a cookie”
> Cognitive Processes
→ how we think
→ e.g. what captures our mind, where we shift our attention - what and how always together (loop)
Generalized anxiety disorder and Social anxiety disorder
- before they were called phobias
- then there were debates, because a phobia is an immediate fear, while those two are about anxiety
Generalized Anxiety Disorder
! Worry
> excessive
> disproportional
> difficult to control
- Restlessness or feeling keyed up or on edge
- Being easily fatigued
- Difficulty concentrating or mind going blank
- Irritability
- Muscle tension
- Sleep disturbance
Worry vs Rumination
- Both:
> repetitive
> no control
> negative content
> verbal
> abstract - Worry
> uncontrollable chain of thoughts, mental problem-solving on issue with uncertain outcome
> GAD
> about the future - Rumination
> repetitive and passive thinking about symptoms of depression and their possible causes
> depression
> about the past
Why do people worry?
- controlled worry for short time is helpful to prepare to possible scenarios
- meta cognitive model
Meta Cognitive Model - key aspects
- Positive beliefs about worry
> helps them prepare
> familiar
> planning for the worse, so if it comes, they were ready - Negative meta beliefs
> worry about the fact that they can’t stop worrying
> very negative beliefs about it
Metacognitive therapy
- treatment for GAD
- challenges both the content of the worry, and the process
- helps clients by rationalizing all worries (content), and challenge the effectiveness of worry (both positive and negative beliefs)
- focuses on attention and mindfulness
> being in the here and now
> tackles sensory/perceptual way of thinking
Avoidance Model
- avoidance→ maintaining factor
- worry: verbal-linguistic
> don’t dive into emotion
> keep abstract, verbal way of thinking
> don’t actually think about consequences of possible bad scenario
> keeps at surface level and stops process of understanding what might happen and sit with that emotion (loop) - addition of positive beliefs (“worrying is helping me deal with negative emotions”)
- Perception of threat → 2. worry (verbal-linguistic) → 3. mental imagery (& positive worry beliefs) → 4. somatic reaction (→ emotional processing→ perception of threat, …)
Contrast Avoidance
- people want to avoid having a big contrast in their emotions
- study: does worry cause/omits flactuations in how we feel?
→ we wouldn’t feel overwhelmed if we were to lose our job because we would already be feeling bad
What is the truth value of the Avoidance Model?
- worry is indeed verbal
- however, it does not decrease arousal
study on Contrast Avoidance
First task (conditions):
1. Neutral activity
> think about what you did over the last weekend
2. Relaxing
> instructions on slowed diaphragmatic breathing
3. Worry
> think about your most worrisome topic and worry about it as intensely as you can
Second task:
- shown very anxious/sad/funny movie clip
→ measure negative affect
what are the results of the study?
-Beginning:
> condition 3 (worry) started off with very negative affect
> other conditions (1&2) didn’t have negative affect
- After movie clip:
> condition 3 did not have a significant difference in affect
> other conditions (1&2) had huge increase of negative affect
→ proves beliefs! (“makes you feel prepared”)
→ avoiding uncertainty
CBT on the role of uncertainty
- CBT is used to target the safe role of uncertainty in people with GAD
- Builds tolerance and acceptance of uncertainty
→ restructuring beliefs (related to uncertainty)
→ behavioral experiments & exposure (to uncertainty)
> e.g. not prepare for an exam if you usually overstress
→ developing problem-solving skills
> e.g. disentangling big problems into smaller ones and learning how to deal with them
Social Anxiety disorder
- afraid of being evaluated, judged negatively
- loop
→ you think people don’t like you → you avoid them → people don’t like you → … - much research on it regards Bias
Bias
- focus point of SAD
(tendency, predisposition, misinterpretation, conviction) - deviation from a healthy control sample
- difference in response to a neutral stimulus
- divergence from objective truth or reality
> mostly automatic and sometimes unconscious
> not necessarily negative, just different from normal
SAD - criteria
- marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others
- the individual fears that her/she will act in a way or show anxiety symptoms that will be negatively evaluated (will be humiliating/embarassing; will lead to rejection or offend others)
- the social situations almost always provoke fear or anxiety
- the social situations are avoided or endured with intense fear or anxiety
Avoidance
- what two types of avoidance do people with SAD engage in?
- avoid going to social situations
- avoid doing smaller things:
> e.g. telling something about yourself (remaining neutral)
> e.g. avoid eye contact
Schultz & Heimberg - 2008
- Model of SAD (perceived audience)
- not made for clinicians, quite complicated
- they tried to understand disorder as a whole
- mental representations are important
> how they think others see them
> this require a lot of cognitive effort
what is an important point of the model of Perceived audience?
what does that lead to?
- comparison between how you think you behave and how you should behave
- leads to:
> the probability of others’ evaluation (not living up to their standards)
> the negative consequences of that evaluation
! evaluation from others is not necessarily the problem; the problem is that you focus on the negative consequences of that evaluation
what symptoms of anxiety are mentioned in the model?
- behavioral (e.g. avoidance)
- cognitive (e.g. negative awareness of others)
- physical (e.g. blushing, trembling)
> extra attention to internal stimuli (e.g. blushing, perceptions, …)
> extra attention outwards towards anything that could confirm the fear (e.g. are they looking at me? no? then I am boring. yes? then I am embarassing)
> negative judgement from perceived not living up to other’s expectations
Schultz & Heimberg - model explanation (article)
1- perception of the audience (anyone who could potentially evaluate the person)
2- this stimulates a mental representation as seen by the audience (what we think others think about us)
3.1- because of negative self-imagery, the person with SAD concludes that the audience has a poor opinion of them
3.2 - belief that audience holds unreachable standards
→ people think bad about me, and they have expectations that I cannot reach
4- this evaluative threat leads to anxiety (behavioral, emotional and cognitive symptoms)
5- cycle (attention bias + external indicators feed into evidence of negative mental representations)
maintenance of fear
- how can people with SAD not extinguish the fear if they keep being exposed to social situations?
Attention→ how can it be measured?
Attention bias in people with SA (article)
- Attention bias towards threat
-
Potential causal role of attention bias to threat
> studies show that attention bias might be a cause of maintentance of SA
> e.g. attention probe training -
Attention bias away from positive stimuli
> diminished processing of positive information linked to maintenance of SA
> studies show that attention training on positive stimuli decreases anxiety (+ emotional reactivity) -
Reduced attentional control
> anxious individuals are unable to regulate their attention
> difference in how easily attention bias develops naturalistically
> inverse relationship between anxiety and attentional control -
Treatment implications and future directions
> CBT is effective in mitigating effects of attention bias
> mindfulness-based stress reduction therapy might also be useful
Measuring attention
It’s difficult to grasp!
- eye tracking
> e.g. show people a face and track how much time they spend (avoiding) looking at the eyes
> e.g. showing positive/negative faces and track how much time they spend looking at the negative one
> e.g. fixation cross
- stroop task (e.g. words like foolish/apple and track how much time it takes to say the color of either)
Hypervigilance & avoidance
- what are they?
- hypervigilance: extra attention to something
> e.g. if spider phobia, you are hypervigilant towards spiders and in a picture, you would see it quicker
> very fast attention towards something negative (in people with SAD) - avoidance
> after seeing something negative, people avoid negative stimuli
! e.g. immediately look at negative image on screen, but after a bit they avoid it
! they are both very common in people with SAD
What is the problem with neutral stimuli for SAD patients? What about positive stimuli?
- they have a negative bias, therefore they see the neutral stimuli as negative
- however, positive stimuli (e.g. smiling face) are even more anxiety provoking
> this is because they think (e.g.) that those persons will approach them
Fixation cross test
- they put neutral and positive faces on screen (left and right sides)
- then there is a quick stimulus (e.g. arrow pointing upwards) that appears either on right or left side
- they are asked to say what the stimulus was
→ they will get it correct more often if it’s on the side of the neutral face
Fixation cross test - Bias scores
- bias scores were calculated by subtracting the mean RT (reaction time) when:
> the probe was in the same location as the emotional face from the mean RT
> the probe and emotional faces were in different locations
-Positive Bias score for angry faces:
> faster RT to probes replacing angry faces than neutral faces
→ vigilance for threat
Fixation Cross Test - Results
- people with social phobia showed hypervigilance and avoidance
- attentional bias towards the angry faces, compared to the happy faces, for people iwth social phobia
- opposite results for controls
(see graph)
Internal vs External attention
- External attention→ hypervigilance and avoidance
- Internal attention→ much harder to measure
> best way is to just ask them about their internal attention
> vibration test
Vibration test
- method
- calculations
- participants are attached to all sorts of measuring heart rate, brain activity, … (fake!!!)
- vibrating device that would “vibrate” if increase in heart rate, blushing, … (fake!!!)
- participants had to focus on the screen where there were stimuli and letters
- they had to respond to whether they felt a vibration or they saw the letter E on the screen
- two conditions: some participants were made anxious (“you’ll have to prepare a speech”), others were in more relaxed state
… - a bias score was calculated by subtracting RT to external probes from RT to internal probes
- positive values reflect faster detection of external than internal probes, and vice versa for negative values
Vibration test - results
- people with high speech anxiety paid attention to the screen when there was no threat, but to the vibration device if there was social threat
- people with low speech anxiety paid attention to the screen both when no threat and social threat
(see graph)
Does attention matter?
- selective attention increases conscious awareness of danger, reinforcing negative beliefs
- socially anxious individuals experience increased anxiety when instructed to focus on themselves
> even when asking “healthy” participants to focus their attention inwards, when having to give a speech they are more anxious - prospective studies indicate that attentional bias is a vulnerability factor for anxiety
Cognitive Bias Modification
- trying to change people’s attention
- lots of studies, most of them not successfull in clinical setting
> they showed that trying to change people’s attention is not super efficient
→ we can try to change people’s cognition (how they think)
Attention training
- e.g. mindfulness meditation (form of attention training, by focusing on your breath)
- training is really necessary
- e.g. probe training on face stimuli
Attention training - probe
- put stimuli behind neutral faces on screen more often
> this way you start focusing attention on neutral faces more - Results:
> people in attention training were significantly more able to reduce anxiety after then training, compared to controls - attention training strengthen the effect of other therapies
What is interpretation?
- drawing a conclusion about an ambiguous situation
- people with SAD have negative interpretation bias, but only relating social situations
What is Interpretation Bias? (in SA people) (article)
- tendencty to interpret ambiguous or neutral stimuli as threatening
> threat interpretation of positive social events
> failure to accept others’ positive reactions at face value
→ this might lead to diminished positive affect
Interpretation study
- people with SAD:
> negative interpretation in social situations
> negative interpretation about self
(see graph)
Article:
- SA was associated with quicker detection of high-intensity anger and fear, in moderate-threat condition
- SA was associated with slower detection of low-intensity sadness and anger, in no-threat condition
→ suggests that the relationship between SA and facial emotion detection may depend on state anxiety & intensity of facial expression
other interpretation bias study (article)
- high SA people more likely to misinterpret disgust faces as in contempt
- nonanxious people more likely to misinterpret disgust faces as happy
→ threat/lack of positive bias among the high-anxious participants was evident only when they were required to make interpretations quickly (not there if more time to see stimulus)
Interpretation bias (article)
- (1) Cause and (2) treatments
(1) Interpretation bias may have causal role for SA
> repeated training to access positive interpretations of ambiguous scenarios resulted in reduction of SA
(2) Treatments
> Cognitive bias modification procedures more efficient and helpful for interpretation rather than attention bias
What are the two kinds of interpretation?
- Offline
> slow, elaborated, rule-based
> permit sufficient time for engagement of relatively reflective cognitive processes
> e.g. rank interpretations in likelihood
> individuals with SAD tend to form negative interpretations of social situations - Online
> fast, automatic, associative
> e.g. completing a missing letter (“they think I am beautif-l” → “u”)
> individuals with SA lack a positivity bias
Recap of the lecture
- anxiety affects a person’s behavior and thoughts
- these processes can be conscious, associative or unconscious
- processing biases are interconnected with other cognitive processes, emotions and behaviors
- models help provide an overview of these relationships, informing both reserach and clinical practice
! grasp what the graphs mean (we should be able to explain them)
! explain how they reinforce each others
! how does it help the clinician?
From now on, the flashcards will be on information that was not covered in the lecture, from the article “Social Anxiety and Social Anxiety Disorder”
What is the Implicit Association Test? Why is it useful in assessment of SA?
The IAT measures implicit associations by categorizing items based on concepts (e.g. self/other) and attributes (e.g. anxious/calm)
- faster response times indicate stronger associations
- it’s particularly useful in the assessment of SA given that it circumvents problems of demand characteristics and self-presentation concerns
What are the findings from IAT studies in SA?
- Individuals with SA exhibit weaker implicit associations between themselves and positive attributes compare to those with low SA (especially in women)
- Those with high SA show weaker implicit self-calm associations and less positive self-associations after social threats like speech tasks
Treatment implications from IAT on SA
- Training individuals with SA to form positive implicit associations - promise in reducing anxiety
- E.g. audio feedback and cognitive preparation can reduce negative implicit associations
- However, while positive implicit associations may influence behaviour (e.g. longer speech task duration), the effects on anxiety reduction are less clear
How does imagery and visual memories affect SA?
- Individuals with SA tend to visualise social interactions from an ‘observer’s perspective’ (i.e. seeing themselves from the outside) rather than a ‘field perspective’ (i.e. seeing through their own eyes)
- This phenomenon contrast with non-anxious individuals, who typically recall both social and non-social situations in a field perspective
- Negative imagery is common and persistent, especially during anxiety-provoking events, and it’s often linked to the onset of SAD
- Intrusive imagery may be less frequent than previously thought, but negative images still evoke stronger emotional responses in individuals with high SA
What is the potential causal role of negative self-imagery?
- Negative self-imagery increases anxiety, worsens self-appraisal and intensifies anxiety-related behaviours
- Holding a negative self-image before a social task worsens anxiety and social performance evaluations, even for nonanxious individuals
- In contrast, holding a benign or positive self-image can have a more positive impact on anxiety and behaviour, though the effects on anxiety reduction are less robust
What does research show about the nonnegative imagery in SA individuals?
- Individuals with high SA tend to have a higher ratio of negative to positive imagery
- When positive images are recalled, they are often less vivid and lack detail
- This contrast in imagery may further reinforce social anxiety, as positive imagery is less accessible or more impoverished than negative imagery
What are the treatment implications of imagery and visual memories?
-
Imagery Rescripting - revisiting negative images, restructuring them with corrective information, and promoting self-compassion
↪ rescripting can reduce negative beliefs, distress from images, and SA -
Video Feedback - used to correct faulty self- perceptions by showing participants their actual performance, often combined with cognitive preparation to improve outcomes
↪ proven effective in improving self-perceptions and reducing anticipatory anxiety in social situations
How do different cognitive biases interact in SA to exacerbate anxiety?
- Cognitive biases - negative self-imagery, attention, and interpretation biases
- Negative self-imagery can speed up the recall of negative autobiographical memories and inhibit positive memories
- self-imagery can influence the interpretation of social information, reinforcing anxiety
- For example, individuals with SA who imagine negative self-images are more likely to interpret ambiguous social cues as threatening
How is memory and interpretation biases linked in SA?
- Individuals with SA are more likely to experience memory intrusions that align with previously biased interpretations
- Attention and interpretation biases influence each other - modifying interpretation biases may help individuals disengage from threatening social cues
- But whether attention biases affect interpretation is still underexplored
What is self-focused attention and how does it contribute to maintenance of anxiety?
- Self-focused attention - awareness of one’s internal experiences, including bodily states, thoughts, and emotions
- In SAD, it prevents individuals from attending to external social cues that could challenge negative self-beliefs = maintenance of anxiety
- Individuals with SAD report higher self-focused attention, which can increase anxiety, but the directionality of this relationship is unclear
- Anxiety may drive self-focus, as shown in studies where anxiety-inducing conditions increased self-focused attention
- Self-focused attention may also be a deliberate coping strategy aimed at suppressing uncomfortable feelings, rather than just an automatic response to anxiety
- However there is limited evidence showing that self-focus directly impairs social performance
- While some studies show studies that self-focus can lead to withdrawal from social situations, the effects are not consistent across all studies
Treatment implications of self-focused attention
- Treatments like CBT often reduce self-focused attention in individuals with SAD
- Task Concentration Training - encourages focusing on external tasks rather than the self
- Mindfulness-based therapies - target experiential avoidance and it may also reduce self-focus by promoting a compassionate stance toward internal experiences
What is emotion regulation in SAD characterized by and how do those individuals deal with emotions?
- Characterized by poor emotional awareness, emotional suppression, and maladaptive beliefs about expressing emotions
- Individuals with SAD tend to suppress emotions and struggle with emotional understanding
- They often fear emotional expression leads to rejection or weakness
What are treatment implications for emotion regulation in SAD?
- Cognitive reappraisal in CBT
- Acceptance and Commitment Therapy (don’t focus on cognitive reappraisal) - more research is needed to explore
- Understanding comorbidity and emotion regulation is also important to explore
How do individuals with SAD experience positive emotions?
- People with SAD often have diminished responses to positive stimuli, which impacts their social functioning
- SAD is associated with reduced positive affect that is independent of depressive symptoms
- Individuals with SAD report less time spent feeling happy and relaxed throughout the day, and participants with relatively higher SA reported fewer and less intense positive emotions across both social and nonsocial situations
What expectations about positive events and positive emotions do individuals with SAD have?
- They estimate positive events to be less likely to occur and anticipate experiencing more frequent and negative reactions to positive social events than do nonanxious individuals
- They also fear positive evaluation because it raises social standards by which they will be evaluated in the future - exacerbate anxiety
How do individuals with SAD regulate their emotions?
- People with SAD down-regulate positive emotions, avoiding or suppressing them, leading to diminished overall positive affect and reduced life satisfaction
- The self-regulation depletion hypothesis suggests efforts to avoid social rejection deplete self-control recources and worsen social interactions
How do biased attention and interpretation contribute to diminished positive affect in SA?
- They contribute to reduced positive affect in SAD, with individuals focusing on threats and misinterpreting positive events
- Self-focused attention in social situations also reduces positive emotions - experience less intense positive affect with camera pointed at them
Treatment implications with focus on improving positive affect
- CBT with focusing on engagemtn in kind acts or loving-kindness meditation
How are anger and SAD related?
- Individuals with SAD reported greater intensity of situationally experienced anger (state anger), disposition to experience anger in a wide range of situations (trait anger), inclination to express anger when criticized, evaluated negatively, or treated unfairly by others (angry reaction), and tendency to experience and express anger without provocation (angry temperament)
- They often suppress or direct the anger inward, leading to poor mental health outcomes
If the anger is not suppressed, how else do SAD individuals deal with anger?
- Some individuals with SAD engage in impulsive, risk-taking behaviors
- This subgroup tends to have more severe interpersonal, physical and substance use issues
Treatment implications related to anger
- Anger issues impact SAD treatment outcomes
- Those with higher trait anger and anger suppression (anger-in) were more likely to have worse outcomes, including higher post-treatment SA and depression
How does engagement in safety behaviours affect individuals with SA?
- Individuals with SA struggle with interpersonal relationships, often due to behaviors perceived as socially awkward
- These behaviors are typically self-protective strategies, known as safety behaviors (e.g., avoiding eye contact, low self-disclosure), aimed at preventing anxiety-triggering outcomes but often leading to negative social results
- High-SA individuals use these behaviors more frequently and across more social situations, which can worsen interpersonal outcomes
What are the two categories of safety behaviours?
- Avoidance (e.g., avoiding eye contact) - typically elicit negative perceptions from others
- Impression- management (e.g., excessive self-monitoring) tend to impede correction of negative predictions about interactions
These subtypes suggest that treatment could be personalized based on the individual’s predominant safety behavior
How are safety behaviours and maintenance of SA?
- Studies show a causal link between safety behaviors and the maintenance of SA
- In controlled experiments, participants who used safety behaviors had higher anxiety and more negative predictions about social interactions
- Reducing safety behaviors has been shown to improve social outcomes, such as reduced anxiety and more positive self-judgments
- In one study, individuals who reduced safety behaviors received more positive responses from others
Treatment implications for safety behaviours
- Safety behaviors are a central target in many cognitive-behavioral treatments for SAD
- Interventions focused on reducing safety behaviors have led to improved social approach behaviors and relationship satisfaction
- Addressing safety behaviors in therapy can enhance interpersonal functioning and reduce SA
What is post-event processing (PEP)?
A thought process in which the individual reviews his
or her own actions and the reactions of the other individual(s) following a social event or in anticipation of a similar upcoming event
- PEP is common in individuals with high SA, where they ruminate on their actions and others’ reactions, reinforcing negative self-impressions and anxiety
What are predictors of PEP?
- SA, negative beliefs, and state anxiety predict PEP, with negative beliefs mediating the SA-PEP relationship
- Fear of discomforting others and anxious rumination also contribute
How do self-focus and PEP relate?
- Self-focus, especially with negative self-imagery, increases negative PEP
- Focusing on others reduces it
- Self-focus leads to more negative evaluations of performance
Treatment implications and PEP
- Reducing PEP improves SA treatment outcomes
- Mindfulness training helps by shifting focus away from self, reducing distress, while distraction training is less effective
