Expert view: a CBT model of anxiety

One of the key differences between those who experience significant anxiety in the form of an anxiety disorder and those who don’t, relates to how information around them is interpreted and the extent to which they perceive their environment to be threatening or dangerous.

Watch the video above which explores how different people might interpret and react very differently to an ambiguous situation (spotting a dog in the park). In this clip, Dr Melissa Snaith highlights two very different hot cross buns for the same scenario. When you’re watching the clip, try and identify the thoughts, emotions, physical feelings/symptoms and behaviour given for both types of reaction. You can record these aspects on a blank hot cross bun which can be accessed here or see Step 2.13 for an editable version.

The young child (with no fear of dogs) interpreted the situation in a positive way (yay! look a dog!). This thought makes her feel happy and excited, and makes her want to go up to the dog to stroke it. On the other hand, the anxious mum interprets the same situation (ie the same dog) in a very different way (‘he looks dangerous’), resulting in physiological symptoms of anxiety and a strong desire to escape from the situation to avoid the dog. This in turn serves to maintain her anxiety (as it prevents her from actually disconfirming that the dog is indeed dangerous—he may actually be friendly but by escaping from the situation and leaving the park, the mum will never find out).

Can you think of any other anxiety disorders where people may show avoidance? How might this help to maintain their fears?

Many people who have problems with anxiety use avoidance to help them manage their fears. This is understandable. If you’re scared of talking to new people because you think you’ll make a fool of yourself, it makes sense, on one level, to just avoid doing what makes you feel scared. If you’re scared of dogs it makes sense, on one level, to avoid them. However, by avoiding people or dogs, or exercise (because of fears about inducing a panic attack) or whatever it is that you are frightened of; you never disconfirm the fear or learn that you can actually cope with it. You never find out if you’ll make a fool of yourself and you never learn that in practice, most dogs are not dangerous. By never trying, you never get the opportunity to disconfirm this belief and so the anxiety remains. Likewise you never learn that you can manage the fear you feel, when you talk to new people and you never learn that you can cope with being close to a dog. By never trying you never get to learn that you can cope with fear.

A note about generalised anxiety disorder (GAD) and avoidance

It’s important to note that GAD may be different from other anxiety disorders, in that there may not be an identifiable source of stress or anxiety which people specifically try to avoid (people may simply experience excessive worry—a series of thoughts or images which spiral out of control, or a sense of dread as if something terrible is about to happen). With the case of GAD, a cognitive behavioural approach may focus less on addressing avoidance (ie associated behaviours). In this case, a more cognitively focused approach is more relevant, in order to help people understand better the nature of their worry, how to live with uncertainty, and how to identify and address unhelpful attitudes to worry which may be helping to maintain them. We’ll be exploring in more detail how GAD can be treated using a more cognitive approach during the final week of this course. In the meantime, we include a self-help resource for GAD in the resource section of this week.

So what does CBT do?

In brief, CBT helps to break vicious cycles where people make assumptions around threat (specific types of thoughts or ‘cognitions’) that subsequently impact on emotions, behaviour and physical sensations. These vicious cycles are problematic because perceptions around threat, invariably lead to feelings of fear and anxiety (both emotionally and physically) which in turn often lead to avoidance (which prevent individuals from disproving the original beliefs around threat).

Rather than addressing the feelings of fear and anxiety directly, which is almost impossible to do (think about how successful it would be to simply tell someone to ‘stop worrying’ for example); CBT attempts to break vicious cycles such as these, by focusing on changing the thoughts or cognitions related to the threat (ie the way in which the situation is interpreted or made sense of) and by changing their behaviours (how someone behaves in response to the situation). We’ll be examining some of these techniques in the last two weeks of the course.