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Samenvatting cognitive behaviors across disorders
Samenvatting van zowel de lectures als de artikelen van cognitive behaviors across disorders.
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SamenvattingWeek 1 - Avoidance
Artikelen
The relationship between rumination, avoidance and depression in a non-clinical sample → 2007
Avoidance come with a lot of disorders. On the short term avoidance seems to resolve peoples
distress, this however leads to maintaining anxiety on the long term. That’s why therapists use
exposure therapy.
Fester’s model: A theory that states that people who are depressed have a tendency to express
avoidant behaviors, like withdrawing themselves or complaining. To counter this BA therapy is used.
(Behavioral activation). To counter maladaptive patterns of thinking and depressogenic thought
content.
The BA model also acknowledges the role of rumination. It’s conceptualized as an escape or
avoidance behavior which does not allow the person to solve their problems. It is different than most
avoidant behaviors, however they all contribute the same. Rumination functions to avoid active
engagement with the environment and to engage in active problem-solving. Rumination is enforced
in two ways:
1. Complaints about life circumstance may be reinforced by others in the depressed person’s
environment
2. Actively avoiding dealing with difficult problems and addressing them by complaining and there for
not having to deal with the distress that comes with it.
The most used model of rumination is the response styles theory of depression.
Response style theory of depression → States that duration, severity and course of depressive
illness are consequences of how one responds to depressive episodes. People who ruminate are
more likely to become depressed and stay depressed for longer. It’s also associated with cognitive
deficits like impoverished problem solving and overgeneral autobiographical memory and negative
cognition.
By dismantling rumination as a construct two factors seem to be contributing a lot:
- Brooding → A tendency towards moody pondering → Associated with short and
long term depression. Brooding is, from the two, most closely linked to depression.
- Reflecting → A tendency to contemplate and reflect → Associated with short term
depression, but not long term depression
There is also an avoidance theory of worry to account for the maintenance of rumination. The model
contends that the function of worry is to escape aversive imagery.
Model of worry → On the ground that worrisome thought is predominantly verbal (rather
than image based), this model proposes that, by avoiding aversive imagery worry limits somatic and
physiological arousal associated with problem content. The reduced concreteness of imagery that
impedes the activation of associated physiological responses. If worries are more abstract and less
concrete and specific in nature, they are less likely to evoke distressing imagery and in turn to evoke
corresponding somatic responses. The problem remains unsolved and worry persists.
,Gray’s (1980) proposed that there are two affect-motivational systems: The behavioral inhibition
(aversive, punishment driven) and behavioral activation system (appetitive or reward-driven).
According to this theory anxiety and depression are characterized by high behavioral inhibitions and
low behavioral activation. Anxiety is correlated with avoidance goals, yet depression isn’t. So the
association between depression and avoidance remain unclear in this aspect.
Because of this new interest in avoidance, new scales have been developed. The Cognitive Behavioral
Avoidance Scale. This has been divided in four parts: behavioral-social, behavioral-nonsocial,
cognitive-social, cognitive- nonsocial. The prediction was that rumination would correlate highly with
these scales.
The findings of the research indicate that individuals who are more likely to engage in behavioral
avoidance re more likely to ruminate and that this association is independent of anxiety.
Conclusion → Rumination, avoidance and depression are highly correlated. Rumination and
behavioral avoidance remained intercorrelated when anxiety was controlled, so this association is
not dependent on anxiety. However, the relationship between cognitive avoidance and rumination
disappeared when anxiety was controlled. Avoidance predicted unique unique variance in depression
scores over and above anxiety and rumination. So it’s important to give thought to avoidance in he
conceptualization of depression.
An experimental investigation of the role of safety-seeking behaviors in the maintenance of panic
disorder with agoraphobia
This study evaluates the hypothesis that safety-seeking behaviors play an important role in
maintaining anxiety because they prevent patients from benefitting from disconfirmatory
experience. Patients suffering from panic disorder with agoraphobia carried out a behavior test,
closely followed by an experimental session, which included a brief (15 min) period of exposure
during which participants either stopped or maintained within-situation safety-seeking behaviors.
When the behavior test was repeated within two days, patients who had stopped their safety-
seeking behaviors during the experimental session showed a significantly greater decrease in
catastrophic beliefs and anxiety than those who had maintained safety-seeking behavior. This
difference was also reflected in questionnaires measuring clinical anxiety. These results are
consistent with the cognitive hypothesis.
Behavioral approaches to the understanding of and treatment of angoraphobia have largely focused
on two process theory. According to this view, the development of avoidance is crucial to the
persistence of classically conditioned agoraphobic anxiety by both preventing and prematurely
terminating exposure to the CS and thereby preventing the extinction of conditioned fear responses.
This theory inspired the development of exposure therapy, which is found to be effective in reducing
phobic anxiety. Both the two process theory and the cognitive behavioral model don’t full explain the
phenomenon of angoraphoia.
According to the cognitive-behavioural theory (Beck, 1976; Beck, Emery, & Greenberg, 1985; Clark,
1986b; Salkovskis, 1996), anxiety disorders arise when situations are perceived as more dangerous
than they really are. Once such a threat is (mis)perceived, at least three mechanisms may be involved
in the maintenance of persistent high levels of anxiety; selective attention to threat-relevant stimuli,
physiological arousal and safety-seeking behaviours. (The latter include avoidance and escape
behaviour; as explained below they may also include other mechanisms.) Each of these reactions
may occur as a response to threat and anxiety, and they may serve to amplify or maintain the crucial
,threat beliefs. The cognitive theory suggests that, in phobic anxiety, safety-seeking behaviour is
particularly important in maintaining perceived threat.
Reactions remain even after disconfirmation. This is due to the fact that people do not only fear a
certain situation but also the outcome. These outcomes differ per patient and result in different
kinds of avoidance behavior. Someone who is afraid of being paralyzed might be extra keen on
exercising as a form of escape behavior. People are usually unaware of their safety seeking behaviors
(avoidance behavior). Sometimes these safety seeking behavior and strategies. The main usefulness
of such a strategy would be in situations where social evaluative concerns predominate; removing
oneself from other people is a helpful strategy both as catastrophe avoidance and removing the
person from the scrutiny of others.
As panic and avoidance become more chronic, the behaviors involved become habitual and
awareness of the specific cognitive component diminishes, although it can often be produced by
further exposure. Often patients express their fears as a desire to escape, therefor they usually
respond with ‘I just had to get out’. Thus, the cognitive analysis of avoidance involves an analysis of
what outcome the patient is avoiding rather than just of the anxiety arousal/relief associated with
the specific situation.
The study: Exposure to feared situations was compared under two conditions. In one condition
patients are encouraged to maintain their safety-seeking behaviours, in the other they are
encouraged to intentionally stop them. It was predicted that the latter would disconfirm their
negative beliefs.
In this experiment, it was found that a brief (15 min) period of exposure to an agoraphobic situation
during which the patient actively sought to decrease safety-seeking behaviours was associated with
substantially greater belief change and fear reduction than a comparable period of exposure during
which safety-seeking behaviours were maintained.
Overall, the results are consistent with the hypothesis that safety-seeking behaviours can play a role
in maintaining key threat beliefs. Such behaviours have the subjective effect of ``saving'' the person
from the potential catastrophe, in the sense that the person comes to believe that the behaviour is
all that stands between them and the feared disaster. This account can explain the potency of graded
exposure, and provides a framework to understand the difficult and unresolved issue of the
, difference between a coping response and an avoidance response. That is, a coping response is one
intended by the person to control anxiety; an avoidance response is intended to prevent perceived
danger. If the cognitive account is correct, then avoidance responses are those behaviours which are
intended to avoid disaster, and these responses have the secondary effect of preventing the
disconfirmation that would otherwise take place. On the other hand, coping responses are those
behaviours brought to bear by a person intending to deal with anxiety alone, with no further fears
about the consequences of the anxiety and so on. The second strategy is not catastrophe based, and
therefore will not interfere with disconfirmation; in fact, it would be expected to enhance cognitive
change because the strategy is based on an alternative, non-catastrophic account of symptoms and
situations.
There is evidence that the type of processes identified in the present experiment generalise beyond
panic to other anxiety problems where avoidance and safety behaviours are prominent such as social
phobia (Wells et al., 1995; Clark, 1996). This may also be true in Obsessional problems (Salkovskis &
Kirk, 1997), post-traumatic stress disorder (Ehlers & Steil, 1995) and specific phobias (Thorpe and
Salkovskis, in press)
A further important factor is how the person believes they can best prevent the perceived danger.
Within this framework, safety-seeking behaviour can be divided into three main categories: (i)
avoidance of the situations to prevent anticipated danger (e.g. the agoraphobic who avoids
supermarkets, the social phobic who refuses invitations to social events); (ii) escape from a situation
when anxiety occurs (e.g. leaving a shop once the symptoms of panic begin, making an excuse to
leave a social situation); and (iii) behaviours carried out within a situation with the intention of
actively preventing the feared catastrophe (e.g. when dizziness leads to the thought ``I'll faint'',
holding onto another person or shopping trolley or sitting down). Some combination of all three
types of safety-seeking can occur in the same individual.
Lecture
‘’If we avoid dealing with mental health problems, we don’t grow’’
‘’Unexpressed emotions will never die’’
Existential therapy → the unknown and concomnant anxiety as surrounding human being
Absense of ultimately solid foundation of our meaning systems
= Ultimate meaninglessness
= Freedom (and responsibility)
Death
➢ Existential givens → Anxiety Defence Mechanisms → Escaping in faith
Freedom → Responsibility for choices given to others
Types of avoidance
Overt escape/avoidance → When an individual does not enter (= avoidance), or prematurely
leaves (= escape), a fear-evoking situation.
Safety behavior → Over or covert avoidance/prevention of feared outcomes
Why do it → It works on short term, not on the long term.
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