Cognitive model of depression and anxiety disorders

The first attempts to study the content of the cognitive sphere were undertaken by A. Beck, who explored dreams, typical thoughts and fantasies of depressed patients in order to verify psychoanalytic theory and detect signs of repressed hostility. Instead, he found two main informative characteristics of the products being studied:

a ) fixation on the topic of real or imaginary loss (death of loved ones, breakup of relationships, a collapse of hope, failure to achieve significant goals) and
b) the so-called “negative deviation”, or “negative triad” – a negative outlook on oneself, on the future and on the world.

Another meaningful characteristic of the basic premises of depressed patients consists in their rigid, imperative character with more frequent, than normal, use of such speech forms as “should” and “should”. A set of such beliefs A. Beck called the “tyranny of obligations”, emphasizing the similarity of this concept with the concept of the superego. He gave an example of typical “responsibilities” of depressed patients: “I should be able to quickly and independently find a solution to any problem”, “I should always be at the peak of productivity”, “I should know, understand and anticipate everything”, “I should never to suffer, I must always be happy and serene. ”

The simplified content of packages, directiveness, and the obvious lack of differentiation testify to the infantile nature of depressive basic beliefs. The following developmental factors are involved in their development and consolidation:

1. Loss of a parent in childhood. There is evidence that depressed patients experience loss in childhood more often than subjects in control groups. This experience can lead to the fact that the loss of any person will be interpreted as an irreversible and injury leaving not passing.
2. The presence of a parent whose belief system revolves around the theme of his own inferiority, or a parent whose system of constructions consists of rigid, rigid rules. Thus, a child can join some non-adaptive schemes based on modeling and social identification. M. Kovak illustrates this possibility with the following example: “At family therapy sessions, one often has to see a parent who reproaches himself for inferiority existing in his imagination, and then expresses his love for the child, saying:“ He’s exactly the same as me. ”
3. Lack of social experience and social skills, negative experience with peers or siblings can impede the empirical testing and reappraisal of early children’s beliefs.
4. A physical defect (such as childhood obesity) contributes to the formation of an “image of the Self” as distinct from others, and the natural shyness associated with the defect and the avoidance of contact can interfere with checking and changing interpersonal- oriented children’s schemes.

According to the cognitive model, the remaining (emotional, motivational, and behavioral) components of the depressive syndrome — melancholy affect, passivity, decreased motivation, self-accusation, andself-destructive (up to suicidal) behavior — are the product of cognitive processes with the above described content.

Cognitive model of anxiety disorders

In the 60s, cognitive-behavioral psychotherapy of anxiety disorders began to emerge . Anxiety is viewed in a cognitive model from an evolutionary perspective – as a defensive reaction that promotes biological survival. The difference in pathological anxiety lies in the fact that it not only does not serve this purpose, but, on the contrary, contributes to maladaptation . In cognitive-behavioral psychotherapy there is no detailed concept of the genesis of pathological anxiety reactions and conditions, however, it emphasizes the role of various factors – cognitive, neurochemical, affective, behavioral, that is, it is an integrative model. The cognitive-behavioral model emphasizes the presence of a predisposition to anxiety disorders (both biological and psychosocial).

Let us dwell on the data that illuminate the sources of increased anxiety or, to put it in terms of the cognitive-behavioral approach, ontogenesis of the hazard scheme.

As mentioned above, attempts to dissolve the normal and pathological anxiety were made even by Freud. The creator of cognitive therapy. Beck, especially elaborates ideas about the cognitive mechanisms of anxiety disorders. He points to the anticipating nature of pathological anxiety, which begins its activity in anticipating danger, not in connection with a threatening situation, but in connection with the possibility of its occurrence.

The main thing is anxiety, as the mobilization of the organism against a possible or actual danger, in anxiety disorders arises where there is no real danger or it is greatly exaggerated in the patient’s imagination. Often, the patient himself is aware of the irrationality of his anxiety, however, he is unable to control it.

This suggests that the inclusion of some deep and poorly understood hazard schemes, which correspond to the most deep, automatic and in fact uncontrollable by the consciousness level of the information processing process, is taking place. In Beck’s terminology, this is the so-called level of “automatic thoughts” (in the terminology of the behavioral approach, there is a reflex inclusion of hazard schemes).

The inclusion of the hazard scheme organizes the entire information processing process, significantly distorting both the external situation and the internal experience (for example, a patient with a social phobia all people seem hostile, and a patient with panic attacks can be interpreted as the beginning of a heart attack). Thus, external information is processed with significant distortions. It is these cognitive distortions that are considered as the main mechanism for increasing pathological anxiety.

We have already written about Beck’s two-component scheme, which includes structural and procedural cognitive components. The structural component is established in the past experience stable cognitive schemes that can be combined into more complex formations – the constellation. Each scheme includes certain rules, beliefs and beliefs, which, for example, make it possible to categorize an object or situation as dangerous. If the scheme is dysfunctional , there is a strong distortion in the processing of information, and all information that does not correspond to the confirmation of the hazard scheme is blocked.

According to A. Beck and his colleagues in the study of anxiety G. Emery, “the symptoms of anxiety disorders are an inadequate automatic response, based on a significant reassessment of the degree of danger and an underestimation of one’s own ability to cope with it.” This is the central characteristic of the scheme of danger in cognitive-behavioral therapy – “I am weak, the world is dangerous.”

The inclusion of a hazard scheme triggers certain cognitive processes. The rules, according to which this scheme works, do not allow to adequately process information, taking into account the totality of circumstances and facts, they are more likely based on the past negative experience than on the actual situation. These are the rules that contribute to such distortions of reality as the generalization of symptoms, i.e. the expansion of the set of stimuli, perceived as dangerous. At the same time, mechanisms such as catastrophisation (danger maximization) are possible, possible due to selective abstraction (ignoring some incentives and selective choice of others) and personalization (attributing neutral events to yourself and interpreting them in the spirit of confirming one’s own vulnerability and hostility of the environment).

These distortions of reality or disturbed thinking characteristic of anxiety disorders are carried out in each individual case through certain rules that are components of the circuit. For example:

1. Every unfamiliar situation should be considered as dangerous.
2. Any person is unreliable until he proves his reliability.
3. It is always better to expect the worst.
4. I can not trust anyone with my security and must control everything.

Another well-known representative of cognitive-behavioral psychotherapy – A.Ellis identifies two emotional and behavioral stereotypes for anxiety disorders: fear-discomfort ( discomfort anxiety ) and “I-fear” ( Ego-anxiety ).

Fear-discomfort, he defines as emotional stress, which arises, as a person believes that:

1) the usual convenience of his life in danger;

2) or he will not be able to get what he wants;

3) finally, it’s terrible, it’s a disaster, if he does not get what he wants, what he expected.

According to Ellis, agorophobic patients first put forward the following absolutist requirements for themselves: “I should not in any way experience or feel discomfort when I drive or go to the store, and this is terrible if I still experience it.” These patients begin to avoid situations in which they feel uncomfortable, referring to the fear of these situations. As a result, they are afraid to feel fear as a result of discomfort and develop fear of fear, obsessively expecting that they will have to endure an extremely unpleasant state in the appropriate situation. At the heart of the process of fear, according to Ellis, lies the unconscious installation to avoid all the troubles and discomfort in life.

Often, along with fear-discomfort, there is an “I-fear”. Ellis defined “I-fear” as an emotional stress that arises when thinking about the threat to self-esteem. The basis of this fear is again an unconscious attitude that it is not terrible to achieve brilliant results, that it is unbearable to be insufficiently highly appreciated by other people. Thus, agoraphobic patients require relaxed, fear-free behavior and feel absolutely insignificant if they do not follow these requirements.

Currently, the cognitive-behavioral model of anxiety disorders is recognized by most authors as the most influential and empirically based, and the effectiveness of cognitive-behavioral psychotherapy for anxiety disorders is confirmed by a large number of studies. Thus, cognitive-behavioral psychotherapy is the first choice method in the treatment of anxiety disorders.

The topic of danger, one’s own vulnerability and inability to cope with the threat is specified with each variant of the disorder. Thus, generalized anxiety “run” schemes with the following cognitive content:

1) constant anticipation of negative events in the future (“ anticipation ” of unhappiness);
2) the notion of the need to meet high standards of quality and quantity of work performed and the conviction of one’s own incompetence in daily affairs, which persists even in the face of obvious competence. Special technicians often detect automatic thoughts like “I can’t cope with it” in such patients;
3) the fear of losing those who help in carrying out this mass of “necessary” cases;
4) the notion of one’s own inability to get along with others and the fear of being ridiculed or rejected as a result of incompetence.

The main cognitive content of agoraphobia with panic disorders is related to the subject of a possible physiological or psychological disaster (death or madness).

Prospective scenario of this disaster is that – sudden onset of acute ailments (heart disease, fainting, etc.) occurs in a situation where there is no access to so-called “safety signals” – output, hospital, doctor, friend, -menthyl Medak, and patient left without help in a hostile or indifferent human environment.

According to Beck and Emery, the likelihood of a panic attack increases with heightened sensitivity to internal sensations and a penchant for catastrophic interpretations of these sensations, which cause and reinforce each other according to the “vicious circle” mechanism.

In ontogenesis Hema “danger” following onfaktory can participate:

1) the death of a significant other – an event preceding the manifestation of agoraphobia with panic attacks and significantly reducing the sense of security and controllability of events;
2) the experience of the early separation and, accordingly, CE paratsionnoy experience anxiety as a child;
3) the experience of “unsafe” attachment in early childhood. 43% of patients with agoraphobia with panic disorders had anxious or rejecting mothers who could not create a sense of security.

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