An overview of Cognitive Behavior Therapy (CBT) for anxiety and, in particular, generalized anxiety disorder (GAD). The clinical case material portion of presentation has been removed.

1. Cognitive (Behavioral) Therapy
of Anxiety Disorders
David J. Walczyk, Ed.D.
C.G. Jung Institute of NY

2. As they relate to the cognitive therapy
of anxiety disorders...
Cognitive Model
General Hypotheses
Etiology
Cognitive Intervention
Case Formulation : GAD

3. Cognitive Model
General Hypotheses
Etiology
Cognitive Intervention
Case Formulation : GAD

4. “Modification of the exaggerated appraisals of threat,
vulnerability, and safety seeking is the primary
objective of cognitive therapy for anxiety disorders.”

5. “The goal of any cognitive intervention is deactivation
of the hypervalent threat schemas and heightened
activation of more adaptive and realistic beliefs about
threat and perceived ability to cope with one’s anxious
concerns.”

8. Cognitive Model
General Hypotheses
Etiology
Cognitive Intervention
Case Formulation : GAD

9. 1. Attentional threat bias
Selective attentional bias for negative stimuli
2. Diminished attentional processing of safety
Automatic attentional shift away from safety cues
3. Exaggerated threat appraisals
Automatic evaluative process that exaggerates the threat
4. Threat-biased cognitive errors
Commit more cognitive errors while processing threatening stimuli

10. 5. Negative interpretation of anxiety
Generate more negative and threatening interpretations
of subjective feelings and symptoms
6. Elevated disorder-specific threat cognition
Elevated frequency, intensity, and duration of
negative automatic thoughts and images
7. Ineffective defensive strategies
Less effective immediate defense strategies and
evaluate defensive strategies as less effective
8. Facilitated threat elaboration
Selective bias threat even towards ambiguous stimuli

11. 9. Inhibited safety elaboration
Inhibitory bias of safety information relevant to
selective themes - fewer themes of safety
10. Detrimental cognitive compensatory
strategies
E.g... worry has a greater adverse effect to enhancing threat salience
11. Elevated personal vulnerability
Lower-self confidence and greater perceived helplessness
in situations relevant to their selective threats
12. Enduring threat-related beliefs
Preexisting maladaptive schemas about particular threats
or dangers and associated personal vulnerability

12. Cognitive Model
General Hypotheses
Etiology
Cognitive Intervention
Case Formulation : GAD

13. “...vulnerability to anxiety disorders involves the
interaction of multiple pathways emerging from
constitutional, developmental, environmental,
personality, and information-processing domains.”

15. “Based on this framework for vulnerability,
we...consider the empirical evidence for the two main
components of the model: an enduring sense of personal
vulnerability and the presence of hypervalent threat
schemas.”

16. Cognitive Model
General Hypotheses
Etiology
Cognitive Intervention
Case Formulation : GAD

17. “Cognitive interventions seek to shift the clients
perspective from one of exaggerated danger and
personal vulnerability to a perspective of minimal
acceptable threat and perceived ability to cope.”

19. What...
Shift threat focus
Tend to enter therapy believing that the cause of their anxiousness
is the situation that triggers their anxious episode
Focus on appraisals and beliefs
An information-processing system that exaggerates the probability and severity
of threat, minimizes personal ability to cope, and fails to recognize aspects of safety.
Modify biased threat, vulnerability, and safety
appraisals and beliefs
Four key elements of faulty cognition : probability estimates, severity estimates,
vulnerability estimates, and safety estimates
Normalize fear and anxiety
Normalize in relation to others, normalize in relation to past experiences,
and normalize in relation to situations.
Strengthen personal efficacy
Correcting erroneous beliefs about personal vulnerability and
perceived inability to deal with anxious concerns.
Adaptive approach to safety
Faculty risk appraisal, enhance safety-seeking processing,
dysfunctional avoidance and safety-seeking behavior

20. How...
Educating the client
Define anxiety and fear, explain consequences, treatment goal, treatment strategy
Self-monitoring and the identification of anxious
thoughts
Identify and record anxious behavior
Cognitive restructuring
Evidence gathering, cost-benefit analysis, decatastrophizing, identifying
cognitive errors, generating alternatives, empirical hypothesis testing
Identifying thinking errors
To reinforce the message to clients that threat perception are inaccurate
Generate and alternative explanation
From rigidity to reflection
Empirical hypothesis-testing
Development and test hypothesis

21. Emerging Hows...
Imaginal reprocessing and expressive writing*
Mindfulness, acceptance, and commitment*

22. Cognitive Model
General Hypotheses
Etiology
Cognitive Intervention
Case Formulation : GAD

23. Primary goal of cognitive therapy of GAD...
“...reduction in frequency, intensity, and duration of worry episodes that would
lead to an associated decrease in automatic anxious intrusive thoughts and
generalized anxiety. This will be achieved by modifying the dysfunctional
appraisals and beliefs as well as the maladapative control strategies that are
responsible for chronic worry.”

25. Case Formulation in conjunction with client...
1. Description of the primary worry concerns
2. Specification of current life goals and personal strivings
3. List of internal and external triggers of worry
4. Identification of metacognitive appraisals of worry of each worry concern
5 Description of idiosyncratic worry control profile
6. Extent of safety and search and negative problem orientation
7. Formulation of the underlying schematic organization responsible for chronic
worry and generalized anxiety.

26. Case Formulation in conjunction with client...
1. Focus on identifying the dysfunctional schemas and faulty metacognitive
processes of worry.
2. Assess the client’s primary worried and associated anxious symptoms (use
ADIS-IV to assess context of worry, presence of safety-seeking responses, and
degree of interference in daily life).
3. Identify client’s personal goals and current concerns.
4. Identify worry triggers (using the Worry Self-Monitoring Form B)
5. Identify client’s metacognitive appraisals of worry
6. Identify Worry Control Strategies using the Cognitive Response to Anxiety
Checklist
7. Develop safety scripts and problem orientation
8. Identify core maladaptive schemas of threat, personal vulnerability, intolerance
of uncertainty, and metacognitive beliefs about worry

27. Primary source...
Cognitive Therapy of Anxiety Disorders
Science and Practice
David A. Clark and Aaron T. Beck
(2011)

28. Thanks!