元认知视角下的强迫症的特征、模型及干预

强迫症的元认知模型认为, 元认知是理解强迫症病理的关键。强迫症患者存在错误的元认知知识信念、消极的元认知体验及不恰当使用元认知策略等问题。强迫症的元认知疗法强调思维过程(如自我聚焦注意、对担忧不变的思维风格和威胁调节的注意策略等)的重要性, 而非思维的具体内容, 并在个体心理干预、团体心理干预等研究中显示出较好的疗效。未来研究应从认知神经科学等视角考查强迫症的记忆等元认知特征, 并进一步验证和修正强迫症的元认知模型。     

Experience and appraisal of worry among high worriers with and without generalized anxiety disorder

Recent research has revealed that a large number of highly worried individuals do not qualify for a diagnosis of generalized anxiety disorder (GAD). This raises the intriguing question of why some high worriers are more impaired and distressed by their worrying than others, particularly when the severity of their worry is the same. The present investigation sought to address this question by examining whether GAD and non-GAD high worriers differ in their actual worry experiences, their subjective appraisals of worry experiences, or both experiences and appraisals of worry. GAD and non-GAD worriers, selected for matching levels of trait worry severity, completed an attention-focus task with thought sampling before and after a brief worry induction. They also completed questionnaires assessing their experiences during and after the worry induction, as well as their general beliefs about worry. GAD worriers experienced less control over negative intrusive thoughts immediately after worrying, reported greater somatic hyperarousal following worry, and endorsed several negative beliefs about worry more strongly than their worry-matched controls. Results suggest that GAD is associated with unique experiences and appraisals that distinguish it from other forms of severe worry.     

Irrational and Metacognitive Beliefs Mediate the Relationship Between Content Beliefs and GAD Symptoms: A Study on a Normal Population

Cognitive Behavioral Therapy (CBT), Rational Emotive Behavior Therapy (REBT) and Metacognitive Therapy (MCT) models show both similarities and differences in conceptualizing anxiety. This work assumes that REBT’s irrational and MCT’s metacognitive beliefs play a mediation role while CBT’s disorder specific content beliefs act as triggers. This hypothesis is tested using a regression model in which metacognitive and irrational beliefs play a mediation role while content disorder beliefs are independent variables. This paper applied this model to generalized anxiety disorder (GAD), a psychiatric diagnosis in which anxiety is the major feature. In GAD, the specific content beliefs are negative problem orientation and intolerance of uncertainty. Therefore, 149 non clinical subjects completed 4 self-report questionnaires: the Negative Orientation to the Problems Questionnaire and the Intolerance of Uncertainty Scale as measures for content cognitive beliefs, the Attitudes and Beliefs Scale for irrational beliefs, and the Metacognitive Questionnaire 30 Items Version for metacognitive beliefs. The generalized anxiety disorder questionnaire was chosen in order to measure anxiety as dependent variable. Regression analyses confirmed that irrational and metacognitive beliefs mediate the relation between cognitive content beliefs and GAD. We clinically interpret mediation as a second level regulation.     

Maladaptive Core Beliefs and their Relation to Generalized Anxiety Disorder

Research has demonstrated that individuals with generalized anxiety disorder (GAD) hold unhelpful beliefs about worry, uncertainty, and the problem-solving process. Extant writings (e.g., treatment manuals) also suggest that other types of maladaptive beliefs may characterize those with GAD. However, these other beliefs have received limited empirical attention and are not an explicit component of cognitive theories of GAD. The present study examined the extent to which dysfunctional attitudes, early maladaptive schemas, and broad self-focused and other-focused beliefs explain significant variance in GAD symptoms, over and above negative and positive beliefs about worry, negative beliefs about uncertainty, and negative beliefs about problems. N = 138 participants classified into Probable GAD and Non-GAD groups completed self-report measures. After controlling for trait anxiety and depressive symptoms, only beliefs about worry, negative beliefs about uncertainty, and schemas reflecting unrelenting standards (e.g., “I must meet all my responsibilities all the time”), the need to self-sacrifice (e.g., “I'm the one who takes care of others”), and less positive views of other people and their intentions (e.g., lower endorsement of views such as “other people are fair”), were unique correlates of Probable GAD versus Non-GAD or GAD severity. Theoretical and clinical implications are discussed.     

Diagnostic Comorbidity in Adults With Generalized Anxiety Disorder: Impact of Comorbidity on Psychotherapy Outcome and Impact of Psychotherapy on Comorbid Diagnoses

The current study examined the impact of comorbidity on cognitive and behavioral therapies for generalized anxiety disorder (GAD) as well as the impact of these therapies on diagnoses comorbid to GAD. Seventy-six treatment-seeking adults with principal diagnoses of GAD received 14 sessions of therapy. Most (n = 46; 60.5%) of the sample had at least one comorbid diagnosis. Although the presence of comorbid diagnoses was associated with greater severity of GAD symptoms at pretreatment, greater severity of comorbid major depression, simple phobia, and social phobia was associated with greater change in symptoms of GAD in response to treatment, with no effect on maintenance of gains during a 2-year follow-up. Further, psychotherapy for principal GAD led to a reduction in number of comorbid diagnoses and in severity of social phobia, simple phobia, and major depression at posttreatment. At 2-year follow-up severity of social and simple phobia remained below pretreatment levels, whereas severity of depression was no longer significantly below pretreatment levels. These results suggest that although people with comorbid disorders enter treatment with more severe GAD symptomatology, they demonstrate greater change, and therefore such comorbidity does not diminish the efficacy of cognitive and behavioral therapies for GAD. In addition, the impact of these treatments for GAD may generalize to reduced severity of simple phobia, social phobia, and major depression; however, gains in severity of major depression are not maintained.     

Metacognitions in Triathletes: Associations With Attention,State Anxiety,and Relative Performance

This study investigated how metacognitive beliefs in triathletes covary with state anxiety dimensions, prior to competition. It also examined how metacognitions relate to concentration, after controlling for state anxiety. Regression analyses revealed that specific metacognitive beliefs were differentially predictive of state anxiety dimensions and concentration. When accounting for the state anxiety variables in a hierarchical model predicting concentration, positive beliefs about worry, negative beliefs about worry, and cognitive anxiety remained as significant predictors. Metacognitive beliefs were also found to differ across time-to-event intervals. Overall, the results demonstrated that a metacognitive framework is a viable pathway for future sporting research.     

Can the components of a cognitive model predict the severity of generalized anxiety disorder?

Over the past decade, a number of well-controlled studies have supported the validity of a cognitive model of generalized anxiety disorder (GAD) that has four main components: intolerance of uncertainty, positive beliefs about worry, negative problem orientation, and cognitive avoidance. Although these studies have shown that the model components are associated with high levels of worry in nonclinical samples and with a diagnosis of GAD in clinical samples, they have not addressed the question of whether the model components can predict the severity of GAD. Accordingly, the present study sought to determine if the model components are related to diagnostic severity, worry severity, and somatic symptom severity in a sample of 84 patients with a primary diagnosis of GAD. All model components were related to GAD severity, although positive beliefs about worry and cognitive avoidance were only modestly associated with the severity of the disorder. Intolerance of uncertainty and negative problem orientation had more robust relationships with the severity of GAD (and with worry severity, in particular). When participants were divided into Mild, Moderate, and Severe GAD groups, intolerance of uncertainty and negative problem orientation distinguished the Moderate and Severe GAD groups from the Mild GAD group, even when age, gender, and depressive symptoms were statistically controlled. Overall, the results lend further support to the validity of the model and suggest that intolerance of uncertainty and negative problem orientation are related to the severity of GAD, independently of sociodemographic and associated clinical factors. The theoretical and clinical implications of the findings are discussed.     

Social phobic interoception: effects of bodily information on anxiety, beliefs and self-processing

It has been suggested that body-state information influences self-perception and negative thinking in social phobia [Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope & F. R. Schneier (Eds.), Social phobia: diagnosis, assessment and treatment (pp. 69-93). New York: Guilford Press.]. This study explored the effects of body-state information on anxiety and cognition in patients with generalised social phobia during a feared social interaction. It was hypothesised that information concerning an increase in pulse rate would lead to increments in anxiety, negative beliefs and self-processing whilst information concerning a decrease in pulse rate would have the opposite effect. The results of this study were generally consistent with the hypotheses. These findings are important as they may help to account for fluctuations in anxiety, negative beliefs and self-processing in social situations that do not present objective social threat. In particular, social anxiety appears to be modulated by body-state information. The implications of the present findings for cognitive therapy of social phobia are briefly discussed.     

Preliminary tests of a cognitive model of generalized anxiety disorder.

Although worry is the central feature of Generalised Anxiety Disorder (GAD), little is known about the factors that contribute to pathological or problematic worry. In a recent cognitive model of GAD, Wells, A. (1995) proposed that negative appraisal of worrying itself (meta-worry or type 2 worry) should be distinguished from other types of worrying (type 1 worry). A central feature of this model is the idea that individuals with GAD hold rigid positive beliefs about the usefulness of worrying as a coping strategy. However, these individuals also hold negative beliefs and appraise worrying as uncontrollable and dangerous. This combination of cognitions and associated responses leads to an increased frequency and generality of worrying, and thus to the pathological worry characteristic of GAD. This paper reports a preliminary test of the hypothesis that meta-worry contributes to problematic and pathological worrying, and this relationship is independent of the frequency of other types of worry. In testing for associations between worry dimensions we controlled for overlaps with Trait anxiety, and the controllability of worrying. Results of a series of regression analyses support the hypothesis that pathological worry is associated with meta-worry and this association is independent of Trait-anxiety and type 1 worry. The clinical implications of these data are briefly discussed.     

Self-focused attention before and after treatment of social phobia

It has been hypothesized that effective psychological treatment for social phobia changes the person's representation of the self in a more positive direction. In order to test this hypothesis, we analyzed 506 thoughts that were endorsed by 23 social phobic individuals while anticipating socially stressful situations before and after exposure therapy. Treatment efficacy was assessed with the Social Phobia and Anxiety Inventory (SPAI) [Turner, S. M., Beidel, D. C., Dancu, C. V., & Stanley M. A. (1989) An empirically derived inventory to measure social fears and anxiety: the Social Phobia and Anxiety Inventory. Psychological Assessment, 1, 35-40)]. Subjects endorsed significantly fewer negative self-focused thoughts after treatment (on average 8.7% of the thoughts) than before treatment (26.5%, p < 0.005). These changes were highly correlated with pre-post difference scores in the social phobia subscale of the SPAI (r = 0.74, p < 0.0001). Implications of the results for the cognitive model of social phobia will be discussed.     

Cognitive assessment of social anxiety: a comparison of self-report and thought listing methods

The goal of the present study was to compare 2 cognitive assessment methods for social anxiety: a thought listing and a self-report method. The focus of this study was on the convergent and divergent validity of these methods using a multi-trait multi-method approach. Furthermore, treatment sensitivity was explored. Fifty-eight patients with social phobia completed thought listings followed by 2 different social stress tasks before and after an exposure group treatment (n = 33), or following a waiting period (n = 25). One task consisted of speaking in front of 2 confederates while the other task involved initiating a conversation with an opposite-sex confederate. Two questionnaires measuring positive and negative self-statements regarding public speaking and social interactions were also completed. To compare the balance of positive and negative thoughts, the State of Mind ratio [positive thoughts/(positive+negative thoughts)] was calculated for both cognitive assessment methods. Results demonstrate that methods related to social interaction anxiety showed better convergent validity than methods related to public speaking anxiety; however, public speaking methods captured treatment effects better than methods related to social interaction anxiety. This study questions the common assumption that different cognitive assessment methods measure the same construct.     

Attentional control in OCD and GAD: specificity and associations with core cognitive symptoms

Obsessive–compulsive disorder (OCD) and generalized anxiety disorder (GAD) are both defined by excessive negatively-valenced cognitions. Although obsessional thoughts are considered essential to OCD and perseverative worry is considered essential to GAD, these excessive cognitions have been found to co-occur in both disorders. Accordingly, a common diathesis may influence the emergence of excessive thoughts in both disorders. The present study examined deficits in attentional control as a cognitive vulnerability that may contribute to both obsessional thought and perseverative worry. Patients with OCD (n = 30), GAD (n = 29), and non-clinical controls (NCC; n = 29) completed measures of obsessional thoughts, perseverative worry, and attentional control. Deficits in self-reported attentional control were found in both OCD and GAD relative to the NCC. However, attentional control was only related to excessive cognition in the GAD patient group, where deficits were associated with increased perseverative worry. Mediational modeling suggested that trait anxiety mediated the relationship between attentional control and perseverative worry in GAD. Implications of these findings for conceptualizing the role of attentional control in the genesis of excessive cognitions in OCD and GAD are discussed.     

Cognitive variables related to worry among adolescents: avoidance strategies and faulty beliefs about worry

Studies aiming to better understand worry have neglected children and adolescents. This constitutes an important limitation considering that excessive worry is frequent among adolescents and that patients suffering from excessive worries associate the beginning of their disorder with adolescence. This study evaluates the cognitive variables associated with worry in a sample of 777 adolescents. It attempts to determine whether cognitive avoidance and false beliefs about the usefulness of worries are present and associated with worries in adolescence. The results showed that participants with a high level of worry used more avoidance strategies and held more beliefs about worry. The results also revealed that avoidance of stimuli that trigger unpleasant thoughts and thought substitution were the major avoidance strategies related to worry among adolescents. The belief that worry helps to avoid future negative events was also related to worry. These findings may suggest that adolescents' worries are maintained by processes similar to those observed among adults.     

The relationship of thought-action fusion to pathologicial worry and generalized anxiety disorder

Meta-cognitive beliefs associated with pathological worry and generalized anxiety disorder (GAD) may encompass the likelihood subtype of thought-action fusion (TAF), the belief that one's thoughts can influence outside events. In the current study of 494 undergraduate college students, positive correlations between scores on the Penn State Worry Questionnaire (PSWQ) and the two Likelihood subscales of the TAF Scale were found, and participants endorsing at least some DSM-IV diagnostic criteria for GAD scored significantly higher on both TAF-Likelihood subscales than participants reporting no GAD symptoms. However, these TAF scales did not predict GAD diagnostic status with PSWQ included as a predictor. In contrast to previous research, the TAF-Moral scale did not correlate with worry. Relationships between TAF, pathological worry, and meta-cognition are discussed in relation to GAD.     

Cognitive Behavior Therapy for Women With Generalized Anxiety Disorder in the Perinatal Period: Impact on Problematic Behaviors

Generalized anxiety disorder (GAD) is the most frequently diagnosed anxiety disorder among women in the perinatal period (pregnancy to one year postpartum). Recent studies have examined the relationship between problematic behaviors and GAD symptoms. Studies in nonperinatal samples indicate that adults with GAD engage in avoidance and safety behaviors and these behaviors are associated with greater symptom severity. Little research has examined the use of problematic behaviors among pregnant or postpartum women. However, preliminary research suggests that these behaviors may have a negative impact on both anxious women and their children. Our aim was to examine the extent to which women with GAD in pregnancy or the postpartum engage in problematic behaviors and whether cognitive behavioral therapy is effective in reducing these behaviors. Fifty-eight women with GAD in pregnancy or postpartum were recruited from a larger clinical trial (Clinicaltrials.gov ID NCT02850523) evaluating the effectiveness of group-based cognitive behavioral therapy (CBGT) for perinatal anxiety disorders. The results indicated that women with perinatal GAD reported high levels of avoidance and safety behaviors and greater engagement in these behaviors was associated with higher levels of worry and related symptoms. CBGT was effective in reducing GAD symptoms and problematic behaviors and a bidirectional relationship was found between changes in worry and problematic behaviors during treatment. Limitations and future directions are discussed.     

The Meta-Cognitive Beliefs Questionnaire: development of a measure of obsessional beliefs

A 67 item self-report questionnaire called the Meta-Cognitive Beliefs Questionnaire (MCBQ) was developed to assess endorsement of beliefs about the importance of control and negative consequences associated with unwanted, ego-dystonic intrusive thoughts, images and impulses. The MCBQ and a battery of questionnaires that assessed symptoms and cognitions of worry, obsessive-compulsive disorder, anxiety, and depression were administered to large samples of undergraduate students. Beliefs about control of intrusive thoughts and perceived negative consequences due to uncontrolled mental intrusions had a unique significant relationship with obsessions, and to a lesser extent, worry. These findings are consistent with current cognitive behavioral theories that suggest an important role for meta-cognitive beliefs in the pathogenesis of obsessions.     

Superior perception of phasic physiological arousal and the detrimental consequences of the conviction to be aroused on worrying and metacognitions in GAD

Although people suffering from generalized anxiety disorder (GAD) often report arousal symptoms, psychophysiological studies show no evidence of autonomic hyperarousal. Hypersensitivity toward and catastrophic interpretation of phasic arousal cues may explain this discrepancy. The authors tested (a) whether GAD sufferers perceive nonspecific skin conductance fluctuations (NSCFs), an indicator of phasic autonomic arousal, better than controls do and (b) whether the conviction to be aroused contributes to the maintenance of worrying and metacognitive beliefs about worrying. Thirty-three GAD sufferers and 34 healthy controls participated in 2 experiments. In Experiment 1, participants were asked to detect their own NSCFs during a signal detection task. GAD sufferers accurately detected more of their NSCFs than did controls, who tended to miss NSCFs. In Experiment 2, participants were instructed to relax following worry induction. While relaxing, they received nonveridical feedback indicating either arousal or relaxation. Arousal feedback conserved negative metacognitive beliefs regarding worrying and also maintained negative mood and worry exclusively in GAD participants. These findings suggest that superior perception of phasic arousal cues and their catastrophic misinterpretation increases worrying, negative metacognitive beliefs about worrying, and anxious mood in GAD.     

The observer perspective: effects on social anxiety and performance

The cognitive model of social phobia by Clark and Wells (Social phobia : Diagnosis, Assessment and treatment (1995)) proposes that individuals with social phobia generate a negative impression of how they appear to others, constructed from their own thoughts, feelings and internal sensations. This impression can occur in the form of a visual image from an external, or "observer", perspective. Although social phobics use this perspective more than controls, the impact of the observer perspective has not been tested experimentally. This study investigated the effects of taking the observer perspective on thinking, anxiety, behaviour and social performance in high and low socially anxious participants. Forty-four participants (N=22 in each group) gave two speeches, one in the observer and one in the field perspective. Use of the observer perspective produced more frequent negative thoughts, more safety behaviours, and worse self-evaluation of performance in both groups. There were also clear trends demonstrating increases in anxiety and in thought belief ratings in the observer perspective compared to the field perspective. Results are consistent with the Clark and Wells model of social phobia. This study also suggests that in low socially anxious individuals, the observer perspective may contain positive information.     

Clark,D. A., & Beck,A. T. (2012) The Anxiety and Worry Workbook: The Cognitive Behavioral Solution New York: The Guilford Press

This article reviews The Anxiety and Worry Workbook: The Cognitive Behavioral Solution by D. A. Clark and A. T. Beck (2012). This workbook offers readers a thorough introduction to a classic, though updated, cognitive behavioral therapy (CBT) approach for anxiety in a self-directed format. The first 8 chapters provide meticulous coverage of cognitive therapy strategies for identifying cognitive distortions relevant to anxiety-inducing thoughts, collecting evidence against such threatening thoughts, and developing alternative statements, as well as detailed explanation of behavioral strategies for reducing safety behaviors and conducting self-guided exposures to feared stimuli. It may therefore appeal to diverse readers who struggle with a range of anxiety problems, but is particularly suited to individuals with symptoms of panic disorder, social phobia, or generalized anxiety. The final 3 chapters discuss specific applications for each of these common conditions. The workbook offers straightforward CBT strategies made accessible via use of engaging metaphors, a wealth of worksheets, and numerous case examples. Moreover, it educates readers about cognitive constructs particularly relevant to specific disorders (e.g., anxiety sensitivity in panic disorder, fear of negative evaluation in social phobia). In summary, this “first self-help workbook for anxiety by the originator of cognitive therapy” does not strive to break new ground, but thoroughly equips the anxious yet self-motivated individual to combat threatening thoughts and engage fears with courage.