Cognitive theory of emotional disorders
Clinical psycho logy has been revolu tion ised by an infl ux of ideas and tech niques derived from cognit ive psycho logy and by the central meta phor that the mind func tions as a processor of inform a tion. The basic assump tion of the clin ical applic a tion of cognit ive theory has been expressed most econom ic ally by Ellis (1962). He suggests that emotional disorder is asso ci ated with irra tional beliefs , partic u larly about the self. Irrational beliefs lead to both unpleas ant emotions and inef fect ive, malad apt ive beha viour. This theory expresses several hypo theses which have become widely accep ted by clini cians working within the cognit ive approach. First, beliefs have a causal effect on emotion and well- being. This hypo thesis differ en ti ates the cognit ive approach from beha vi our ism. Second, beliefs, as causal agents, are expressed in verbal, propos i tional form, and can be accessed consciously during therapy. This hypo thesis distin guishes the cognit ive approach from most psycho dy namic approaches, in which “latent” beliefs are uncon scious. Third, therapy should be direc ted towards chan ging beliefs through restruc tur ing cogni tions, as in Ellis’ (1962) rational emotive therapy, in which the patient is taught to recog nise and modify irra tional, harmful self- beliefs.
The core assump tions of the cognit ive approach just described are not in them selves suffi cient to provide a work able model of emotional disorder. The most obvious diffi culty is the resist ance to change in irra tional beliefs often encountered clin ic ally. The person’s self- know ledge is not simply an internal
“fi le” of discon nec ted beliefs which the ther ap ist can erase and replace with more real istic propos i tions. People seem to construct and revise self- beliefs actively on the basis of some internal set of ground rules for inter pret ing the world.
Emotionally disturbed patients may be char ac ter ised not so much by their specifi c beliefs as by the general frame works they use to under stand their envir on ment and their place in it. In other words, clini cians must address the cognit ive processes by which patients arrive at their malad apt ive inter pret a tion of the world. Another
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2 Introduction
factor is the possib il ity of uncon scious cognit ive processing. Studies compar ing intro spect ive reports of processing with object ive data have shown that people lack aware ness of even some quite complex mental oper a tions (Nisbett & Wilson, 1977). A patient’s self- reports will provide only an incom plete and possibly distor ted picture of their actual cognit ive func tion ing. Psychopathology may be infl u enced by “auto matic” processes, which may be more diffi cult to infl u ence than conscious beliefs. In addi tion, people may fi ll the gap in conscious aware ness by making attri bu tions . The mind seems to abhor an inform a tional vacuum, so, if we exper i ence an emotion, we tend to search for an explan a tion, which may be incor rect. For example, Abramson, Seligman and Teasdale (1978) suggest that depress ives are char ac ter ised by faulty attri bu tions for negat ive events, tending to blame them selves rather than other agen cies. Typically, the person is aware of the attri bu tional belief, but not the uncon scious and possibly auto matic inform a tion processing which gener ates it. In prac tice, we may need quite a complex cognit ive model, incor por at ing a variety of struc tures and processes (the “archi tec ture” of the model), to provide a satis fact ory basis for therapy.
Next, we consider Beck’s (1967; 1976; Beck, Rush, Shaw, & Emery, 1979;
Beck, Emery, & Greenberg, 1985) theory of emotional disorders, which offers perhaps the most infl u en tial and compre hens ive account of cognit ive processing in emotional disorders. This approach is based on constructs derived from exper- i mental psycho logy, and is suppor ted by evid ence from both clin ical obser va tion and rigor ous exper i ment. Our account will illus trate the need for differ en ti ation of cognit ive struc tures and processes, the role of the person’s active construc tion of a world- view, and the contri bu tion of auto matic processes, as just described.
Beck’s cognit ive theory
Beck’s approach to emotional disorders is essen tially a schema theory. It proposes that emotional disorders result from and are main tained by the activ a tion of certain memory struc tures or schemas. Schemas consist of stored repres ent a tions of past exper i ence and repres ent gener al isa tions which guide and organ ise exper- i ence. While indi vidu als possess many differ ent schemas, each one of which repres ents a differ ent array of stim u lus- response confi g ur a tions, one of the most import ant schemas involved in psycho path o logy is the self- schema (e.g. Markus, 1977). This partic u lar schema is used specifi c ally to process inform a tion about the self.
The basic tenet of Beck’s theory is that vulner ab il ity to emotional disorders and the main ten ance of such disorders is asso ci ated with the activ a tion of under- ly ing dysfunc tional schemas. The activ a tion of such schemas is accom pan ied by specifi c changes in inform a tion processing, which play a role in the devel op ment and main ten ance of the affect ive, physiolo gical and beha vi oural compon ents of emotional disorders. These changes in processing are appar ent as an increase in negat ive auto matic thoughts in the stream of conscious ness and as cognit ive distor tions or “think ing errors” in processing. These distor tions take the form of
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Beck’s cognit ive theory 3
biases or incor rect infer ences in think ing, which we discuss in more detail later in this chapter. Beck’s approach is a tripart ite concep tu al isa tion which differ en ti- ates between three levels of cogni tion under ly ing emotional prob lems: the level of cognit ive memory struc tures or schemas, cognit ive processes termed think ing errors (Beck et al., 1979), and cognit ive products, namely negat ive auto matic thoughts. The basic cognit ive model is depic ted in Fig. 1.1.
Negative automatic thoughts
Each emotional disorder is char ac ter ised by a stream of invol un tary and paral lel negat ive “auto matic thoughts” (Beck, 1967). In anxiety these thoughts concern
FIGURE 1.1 Beck’s cognit ive model of emotional disorders.
Early experience
Dysfunctional schemas formed
Critical incident
Schema activated
Negative automatic thoughts
Symptoms of anxiety/depression (affective, cognitive, behavioural etc.)
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4 Introduction
themes of danger (Beck, 1976; Beck et al., 1985; Beck & Clark, 1988), whereas in depres sion thoughts about loss and failure predom in ate. The content of thought in depres sion has been referred to as the negat ive cognit ive triad, which is domin- ated by a negat ive view of the self, the world and the future (Beck et al., 1979;
Beck & Clark, 1988). In stress syndromes domin ated by hostil ity, the content of auto matic thoughts concern themes of restraint or assault (Beck, 1984). The
“chain ing” (Kovacs & Beck, 1978) of specifi c cognit ive content to a disorder is the basis of the content specifi city hypo thesis in schema theory, which asserts that emotional disorders can be differ en ti ated on the basis of cognit ive content (e.g.
Beck et al., 1987). Normal emotional reac tions of anxiety and sadness are also asso ci ated with negat ive thoughts of danger and loss, etc., but in the emotional disorders there is a strong fi xa tion on these themes.
The term auto matic thoughts was used by Beck (1967) to describe cognit ive products in emotional disorders because they occur rapidly, are often in short- hand form, are plaus ible at the time of occur rence and the indi vidual has limited control over them. The content of these thoughts mirrors the content of under- ly ing schemas from which they are purpor ted to arise.
Dysfunctional schemas
The under ly ing schemas of vulner able indi vidu als are hypo thes ised as more rigid, infl ex ible and concrete than the schemas of normal indi vidu als. Dysfunctional schemas are considered to remain latent until activ ated in circum stances which resemble the circum stances under which they were formed. Their range of activ- a tion may gener al ise and this may lead to an increased loss of control over think ing (Kovacs & Beck, 1978).
Dysfunctional schemas have an idio syn cratic content derived from past learn ing exper i ences of the indi vidual. There are at least two levels of know ledge repres en ted in the dysfunc tional schema which play a role in emotional distress (Beck, 1987): propos i tional inform a tion or assump tions, which are char ac ter ised by if–then state ments (e.g. “If someone doesn’t like me I’m worth less”), and at the deepest level abso lute concepts or “core beliefs”, which are not condi tional (e.g.
“I’m worth less”).
In anxiety disorders, the schemas contain assump tions and beliefs about danger to one’s personal domain (Beck et al., 1985) and of one’s reduced ability to cope.
In gener al ised anxiety, for example, a variety of situ ations are appraised as danger ous and indi vidu als have assump tions about their general inab il ity to cope.
In contrast, panic disorder patients tend to misin ter pret bodily sensa tions as a sign of imme di ate cata strophe (Clark, 1986) and thus have assump tions about the danger ous nature of bodily responses. In the phobias, patients asso ci ate a situ ation or an object with danger and assume that certain calam it ies will occur when exposed to the phobic stim u lus. Unfortunately, the paucity of research on the content of dysfunc tional schemas in differ ent anxiety disorders prevents fi rm conclu sions about schema content in these disorders.
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The role of beha viour in cognit ive theory 5
According to Beck et al. (1979), the depressed indi vidual has a negat ive self- view, and the self is perceived as inad equate, defect ive or deprived and as a consequence the depressed patient believes that he or she is undesir able and worth less. The Dysfunctional Attitudes Scale (Weissman & Beck, 1978) was developed to assess dysfunc tional schemas in depres sion. The scale consists of a range of atti tude clusters (e.g. “I can fi nd happi ness without being loved by another person”; “If others dislike you, you cannot be happy”; “My life is wasted unless I am a complete success”), and responses are made on a seven- point scale ranging from “disagree totally” to “agree totally”. The higher the overall score on the scale, the greater the level of dysfunc tion al ity and prone ness to depres sion.
Cognitive distor tions
Once activ ated, dysfunc tional schemas are thought to over ride the activ ity of more func tional schemas. Although schema- based processing is econom ical, because indi vidu als do not have to rely on all of the inform a tion present in stim- u lus confi g ur a tions in order to inter pret events, this type of processing sacri fi ces accur acy for economy of processing. A consequence of dysfunc tional schema processing is the intro duc tion of bias and distor tion in cogni tion. These processes have been termed “think ing errors” by Beck et al. (1979) and are concep tu al ised as playing an import ant role in the main ten ance of negat ive apprais als and distress.
Specifi c errors have been iden ti fi ed:
• Arbitrary infer ence : Drawing a conclu sion in the absence of suffi cient evid ence.
• Selective abstrac tion: Focusing on one aspect of a situ ation while ignor ing more import ant features.
• Overgeneralisation: Applying a conclu sion to a wide range of events when it is based on isol ated incid ents.
• Magnifi cation and minim isa tion: Enlarging or redu cing the import ance of events.
• Personalisation: Relating external events to the self when there is no basis to do so.
• Dichotomous think ing: Evaluating exper i ences in all or nothing (black and white) terms.
Other cognit ive distor tions partic u larly prom in ent in anxiety are atten tion binding and cata stroph ising (Beck, 1976). The former is a preoc cu pa tion with danger and an invol un tary focus on concepts related to danger and threat. Catastrophising involves dwell ing on the worst possible outcome of a situ ation and over es tim at ing the prob ab il ity of its occur rence.
The role of beha viour in cognit ive theory
Behavioural responses in emotional disorders can play a role in the main ten ance of dysfunc tional states. Phobic disorders are often accom pan ied by varying
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6 Introduction
degrees of overt avoid ance of feared situ ations. Aside from such gross avoid ance, more subtle forms of avoid ance also occur in anxiety disorders such as panic, agora pho bia and obsess ive- compuls ive disorder. The percep tion of danger in these disorders leads to attempts to avoid the threat. In panic disorder there is a misin ter pret a tion of phys ical sensa tions or mental events as a sign of imme di ate cata strophe such as collapsing or going crazy. Following such cogni tions, panick ers may employ subtle avoid ance or “safety beha viours” aimed at prevent ing the calam ity (Salkovskis, 1991). For example, patients who believe that they are suffoc at ing may attempt to take deep breaths and consciously control their breath ing. Patients who believe that collapse is immin ent may sit down, hold onto objects or stiffen their legs. Since the cata strophe does not actu ally occur, patients may then attrib ute its non- occur rence to having managed to save them- selves. In this scen ario, safety beha viours can have two effects which contrib ute to the main ten ance of anxiety. First, partic u lar safety beha viours may exacer bate bodily sensa tions. Deep breath ing, for example, can lead to respir at ory alkal osis and the range of symp toms asso ci ated with hyper vent il a tion (dizzi ness, disso ci- ation, numb ness, etc.), and these sensa tions may then be misin ter preted as further evid ence of an imme di ate calam ity. Second, if panick ers judge that they have managed to save them selves from disaster, their safety beha viours prevent discon- fi rm a tion of cata strophic beliefs concern ing bodily sensa tions. It follows from this that manip u la tions which include a system atic analysis of safety beha viours and preven tion of these beha viours during expos ure tasks may increase treat ment effects. Initial data from social phobics is consist ent with this proposal (Wells et al., in press).
Behaviours aimed at controlling cogni tion can have a similar effect in prevent ing discon fi rm a tion of beliefs concern ing the danger ous nature of exper- i en cing certain cognit ive events. In addi tion, attempts to control or avoid unwanted thoughts may lead to a rebound of unwanted thoughts (e.g. Clark, Ball, & Pape, 1991; Wegner, Schneider, Carter, & White, 1987). This may be partic u larly relev ant in the devel op ment of obses sional prob lems and prob lems marked by subject ively uncon trol lable worry (Wells, 1994b), as discussed in Chapter 7. The applic a tion of safety beha viours relies on self- monit or ing of bodily and cognit ive reac tions which are appraised as danger ous. This type of self- direc ted atten tion could have dele ter i ous effects of intensi fy ing internal reac tions (see Chapter 9).
In depres sion, self- defeat ing and with drawal beha viours can serve to main tain or strengthen dysfunc tional beliefs. Depressive symp toms may be appraised as evid ence of being inef fec tual, which then leads to further passiv ity and hope less- ness (Beck et al., 1979). Negative self- beliefs can give rise to self- defeat ing beha- viours which rein force these beliefs. For example, indi vidu als who believe that they are unlove able may stay in abusive rela tion ships because they negat ively appraise their ability to form better rela tion ships. Young (1990) terms such responses “schema processes”, which prevent discon fi rm a tion of beliefs and main tain and exacer bate stress ful life circum stances.
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Clinical models and scientifi c theory 7
Cognitive model of panic
Clark (1986) developed a cognit ive model of panic which has many over lap ping features with Beck’s model of anxiety. In the model, panic attacks are considered to result from the misap praisal of internal events such as bodily sensa tions.
Sensations are misin ter preted as a sign of an imme di ate impend ing disaster such as having a heart attack, suffoc at ing or collapsing. The sensa tions most often misin ter preted are those asso ci ated with anxiety, although other sensa tions—for example, those asso ci ated with normal bodily devi ations or low blood sugar—
may also be misin ter preted. Similar misin ter pret a tions are considered central in health anxiety (e.g. Warwick & Salkovskis, 1990), but in this latter disorder the appraised cata strophe is more protrac ted.
Clark’s (1986) model of panic proposes a specifi c sequence of events which culmin ate in a panic attack. To begin with, any internal or external stim u lus which is perceived as threat en ing produces a state of appre hen sion and asso ci ated bodily sensa tions. If these sensa tions are misin ter preted in a cata strophic way, a further elev a tion in anxiety results and the indi vidual becomes trapped in a vicious circle which culmin ates in a panic attack (Clark, 1986; 1988). Once panic attacks are estab lished, two partic u lar processes are involved in main tain ing the problem: select ive atten tion to bodily cues, and safety beha viours of the type discussed previ ously. Beck (1988) also refers to “atten tion fi xa tion” on internal sensa tions in panic and claims that panic patients are “hyper vi gil ant” for bodily sensa tions.
In addi tion, there also appears to be an inab il ity of the indi vidual during panic to
“apply reas on ing and logic or to draw on past exper i ence or previ ous know ledge to re- eval u ate the symp toms or to examine the fright en ing concept object ively”
(Beck, 1988, p. 92). Beck (1988) suggests that the predis pos i tion to exper i ence panic under certain circum stances may take the form of chron ic ally increased physiolo gical arousal, an increased tend ency to exag ger ate or misin ter pret the meaning of some symp toms, and in partic u lar an inab il ity to reappraise these misin ter pret a tions real ist ic ally. Hypervigilance and loss of reappraisal ability during panic can be construed as a form of cognit ive distor tion which contrib utes to the vicious circle of panic.
Clinical models and scientifi c theory
Beck’s cognit ive model repres ents a crucial and most infl u en tial devel op ment for the treat ment and concep tu al isa tion of emotional prob lems. We owe much of the work in this book to the impetus and basic frame work provided by this model.
However, as with most models, we see a number of limit a tions with the present model. First, it is based on concepts such as schemata which are diffi cult to falsify exper i ment ally. Second, the model as it presently stands only considers limited dimen sions of cogni tion and neglects broader aspects such as atten tion, regu la tion of cogni tion, levels of control of processing, and the inter ac tion between vari et ies of processing. Third, the use of cognit ive psycho lo gical concepts such as schemas is