Dr. Frances Meeten Cognitive approaches to understanding emotional disorders

 Mechanisms of worry  Embodiment of emotion  MBCT for older people Who am I?

OVERVIEW: Learning outcomes - Understand cognitive explanations of two common psychopathologies  A cognitive model of depression  Cognitive model of anxiety  Meta-cognitions in anxiety  Intolerance of uncertainty in anxiety  The utility of examining cognitive processes across disorders

COGNITIVE MODEL Dysfunctional ways of thinking generate psychopathology symptoms MEDICAL MODEL Biological causes of psychopathology SOCIAL VARIABLES Socio-economic status, geographical factors Diagram taken from: psychosomatic-disease-part-2/

MAJOR DEPRESSION Characterisation according to the Diagnostic and statistical manual (DSM - IV-TR, APA, 2000): Cognitive features Depressed mood Negative beliefs about the world Hopelessness Behavioural features Inertia Lack of energy Physical features Insomnia Weight loss/gain Motivational features Diminished interest in activities Prevalence: World Health Organization (WHO) projections indicate that depression will be the highest ranked cause of disease burden in developed countries by the year 2020.

Cognitions (thoughts and beliefs) shape one's behaviours and emotions. Maladaptive cognitions precede and cause psychological disorders. Aaron T. Beck Beck’s Cognitive theory of depression (Beck, 1967)

Beck (1967): 3 main levels of thinking in onset, maintenance, and exacerbation of depression. Depressive self-schemas Maladaptive beliefs/assumptions Negative automatic thoughts (NATS)

Schemas Depressive self-schemas result in a negative understanding of the world and negative core beliefs e.g. ‘I am inept’  E.g. Evans et al. (2005) A structure such as a schema can be adaptive as it speeds processing, but it can be maladaptive when information is selectively encoded and retrieved i.e. negative information at the expense of positive or neutral information. Schema: Cognitive patterns used to categorise experiences and events Mental plans that are abstract and that serve as guides for action, as structures for interpreting information, as organised frameworks for solving problems. (Reber, A. S. 1985: The Penguin Dictionary of Psychology. Penguin Books) Depressive Schema

Core beliefs that are organised within the negative self-schema influence the development of dysfunctional beliefs. (Dozois & Beck, 2008) Core beliefs Intermediate dysfunctional beliefs: Often ‘all or nothing’ or ‘if/then’ beliefs that are contingent on self- worth. “If I do not do as well as other people, then I am inferior” Individuals with negative core beliefs often generate compensatory strategies and rules e.g. “I must always succeed in everything I do” Activation of depressotypic self-schemas and negative core beliefs result in: Cognitive errors/biases And Negative automatic thoughts

Cognitive biases Systematic biases in thinking in depression maintain the individual’s belief in the validity of negative concepts (Beck, 1967) e.g. Extreme thinking: All or nothing type thoughts i.e. “I am a terrible person” Selective attention: Selectively remembering a negatively biased version of events. Arbitrary inference: Drawing a specific conclusion in the absence of evidence. “I only did well in the test because they probably made it easier this year”

- NATs are spontaneous and occur effortlessly and frequently. - NATs influence emotions, behaviours, and physiological responses. - NATs occur spontaneously and are often left unchecked or unchallenged, which makes a depressed individual feel more negative and more depressed. iveronicawalsh.wordpress.com Negative Automatic Thoughts

The cognitive triad Three major cognitive patterns that lead an individual to perceive themselves, the world, and the future in a negative way. SELF Attribute failure to self Attribute success to others WORLD Interpretation of everyday experiences in a negative way. Failures are global FUTURE Current difficulties will continue indefinitely. Problems are timeless Negative automatic thoughts (NATS) often take this form

Beck’s cognitive model From Dozois & Beck (2008) Early experience e.g. rejection and criticism from parents Negative core beliefs/schemas I am incompetent Negative life event Activation of schema Nothing ever goes right for me Cognitive biases Negative automatic thoughts Depression

Maintenance process for depression Depressed Mood Negative cognitive biases and symptoms e.g. fatigue/poor concentration More negative view of self Loss of pleasure/achievement Reduced activity Reduced coping Nothing changes Increased hopelessness From: Westbrook, Kennerley, & Kirk (2007)

Negative cognitive biases Beck suggested that a depressive schema served to maintain negative cognitions and information processing biases. STROOP TASK (e.g. Gotlib & McCann, 1984) - Name the colour of the word.  GREEN  RED  YELLOW  HAPPY  SUN  LAUGHTER  PAIN  LOSS  SORROW People who are depressed are more likely to show greater attentional bias to negative information.

Summary: Beck’s cognitive theory of depression has highlighted how maladaptive thinking can shape the way we perceive ourselves and the world around us. Cognitive biases influence our thoughts, behaviours, and belief systems. Summary: A cognitive model of depression

GENERALISED ANXIETY DISORDER (GAD) Excessive anxiety and worry lacking closure (Davey, 1994; Davey & Levy, 1998; Wells, 1995) Long chains of negative thought: ‘What if ?’ questioning style (Davey & Levy, 1998; Vasey & Borkovec, 1992) Endemic negative mood (Startup & Davey, 2001; Vasey & Borkovec, 1992).

We all worry…. But what is it that leads people into pathological worrying that interferes with their ability to get on with daily life?  Uncertain about the future?  Unable to cope with life stresses?  Unable to see the ‘brighter side’?  Finds that worrying is helpful?

COGNITIVE MODELS OF ANXIETY There are a number of cognitive models of anxiety. We will discuss two: 1.Well’s (1995) Metacognitive model of worry and generalised anxiety disorder (GAD). 2.Intolerance of Uncertainty (IU) in worry and generalised anxiety disorder (GAD) (Koerner & Dugas, 2006; Ladouceur, Gosselin, & Dugas, 2000).

Meta-cognition refers to the knowledge and beliefs we have about our cognitive system – the way we appraise things, regulate our own thoughts. Dysfunctional beliefs about our own thoughts (cognitions) are the basis for the development and maintenance of clinical problems e.g. anxiety/depressive rumination. Metacognitive model (Wells, 1995, 2006)

Metacognitive model (Wells, 2006)  Makes the distinction between positive (type 1) and negative (type 2) beliefs about worrying (Wells, 2006). Type 1 worrying: Positive metacognitive beliefs Worry as a coping strategy “If I worry a negative event – I will be prepared” “ If I worry about all possibilities – I will avoid failure” Changes in mood/emotion Type 2 worrying Negative beliefs about worry: Worry is uncontrollable, worry is harmful “Worrying is uncontrollable – I will lose my mind because of worrying” Associated with pathological worrying

Figure 1. Cognitive model of GAD. From Cognitive Therapy of Anxiety Disorders: A Practice Manual and Conceptual Guide (p.204), by A. Wells, 1997, Chichester, UK: Wiley. Copyright 1997by John Wiley and Sons, Ltd.  Wells (1997) views Negative cognitions or beliefs about worry as critical in GAD.  In meta-worry a person will appraise their worry thoughts as being uncontrollable and dangerous

High worriers (including people with GAD) hold beliefs about worrying. Positive beliefs about worry e.g. worrying is a useful task to undertake (not necessarily pathological). Negative beliefs about worry e.g. worrying in uncontrollable and harmful Negative beliefs about worry result in avoidance behaviours, which maintain maladaptive beliefs. Summary of metacognitive model of anxiety Individuals with GAD endorse significantly greater levels of negative beliefs concerning the uncontrollability and danger of worry than other groups (Cartwright-Hatton & Wells, 1997). Meta-worry beliefs distinguished GAD individuals from individuals without GAD. Thus there is a relationship between negative metacognitions and GAD (Wells, 2005). Evidence? Some examples…

Intolerance of uncertainty model (Dugas, Gosselin, Ladouceur, 2001, Koerner & Dugas, 2006)) Intolerance of uncertainty (IU) is a dispositional characteristic and those who experience IU find uncertainty stressful, upsetting, they think being uncertain about the future is unfair and that unexpected events are negative and should be avoided (Buhr & Dugas, 2002). IU promotes heightened sensitivity to ambiguous or innocuous thoughts or situations resulting in processing biases towards uncertainty and the perception of uncertainty as threatening.

Figure from: Dugas, Gagnon, Ladouceur, Freeston (1998) Model of GAD based on Intolerance of Uncertainty Dugas, Gagnon, Ladouceur, Freeston (1998) 1. IU exacerbates “what if questions” about worry 2. Individuals with GAD hold positive beliefs about worry 3. Worriers have poor Problem solving confidence and appraisals 4. Cognitive avoidance means threatening material is not processed – which serves to maintain worry

What’s the evidence? Correlational evidence: Individuals with high IU appraise ambiguous situations as more disconcerting than those with low IU (Koerner & Dugas, 2008). Experimental evidence: Manipulating tolerance to uncertainty increases worrying when tolerance is low e.g. Ladouceur et al. (2000) and Meeten et al. (2012). IU and positive beliefs about worry: IU may perpetuate worry through a number of positive beliefs about worry 1.Worrying is adaptive: It helps problem solve and increases motivation 2.Worry dampens emotional reactions by preparing you for surprise/disappointment 3.Worry shows positive aspects of your personality i.e. you are caring… (Koerner & Dugas, 2006) Are the two models of GAD compatible?

Summary IU is a higher order process thought to directly affect worry. There is a positive correlation between high IU and pathological worry and reducing IU has been found to reduce worry. One way in which IU is thought to exacerbate and maintain worry is through positive beliefs about the usefulness of worry.

Cognitive processes across psychological disorders: A transprocess model Psychological disorders are more similar than different in terms of the cognitive behavioural processes that maintain them (Harvey et al., 2004) Co-occurrence of psychological disorders Information processing biases in depression and anxiety Attentional biases in depression and anxiety Dysfunctional ways of thinking generate psychopathology symptoms

SUMMARY 1.What does the cognitive model seek to explain? Dysfunctional ways of thinking generate psychopathology symptoms. 2.Beck’s cognitive model of depression Three levels of ‘thinking’ depressive schemas, maladaptive beliefs, and NATs. 3. Cognitive models of anxiety Meta-cognitive model: Type 1 and type 2 worries IU in worry: IU directly affects worry and indirectly affects positive beliefs about worry. 5. Cognitive processes across psychological disorders

References Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. New York: Harper and Row. Republished as: Beck, A. T. (1970). Depression: Causes and treatment. Philadelphia: University of Pennsylvania Press (Beck’s model of depression) Dozois, D.J.A. & Beck, A.T. (2008). Cognitive schemas, beliefs, and assumptions. In K.S. Dobson & D.J.A. Dozois (Eds.), Risk factors in depression. London Academic Press. (Available online via ScienceDirect).(Nice explanations of main factors of cognitive model of depression) Evans, J., Heron, J., Lewis, G., Araya, R., & Wolke, D. ( 2005 ). Negative self-schemas and the onset of depression in women: A longitudinal study. British Journal of Psychiatry, 186, 302 – 307. (evidence that negative self-schemas are a risk for onset of depression) Gotlib, Ian H.; McCann, C. Douglas (1984). "Construct accessibility and depression: An examination of cognitive and affective factors". Journal of Personality and Social Psychology 47 (2): 427–439. Ingram, E. (2003). Origins of cognitive vulnerability to depression. Cognitive Therapy and Research, 27, (Examination of how depressive self-schemas may develop). Westbrook, D. Kennerley, H. & Kirk, J. (2007). An introduction to Cognitive Behaviour Therapy: Skills and application. Sage. London Depression Anxiety Buhr, K., & Dugas, M. J. (2002). The intolerance of uncertainty scale: psychometric properties of the English version. Behaviour Research and Therapy, 40, Cartwright-Hatton, S. & Wells, A. (1997). Beliefs about worry and intrusions: The Meta-Cognitions Questionnaire and its correlates. Journal of Anxiety Disorders, 11, Dugas, M. J., Gagnon, F., Ladouceur, R., & Freeston, M. H. (1998). Generalized Anxiety Disorder: A preliminary test of a conceptual model. Behaviour Research and Therapy, 36, Koerner, N., & Dugas, M. J. (2006). A cognitive-affective model of generalized anxiety disorder: the role of intolerance of uncertainty. In G. C. L. Davey, & A. Wells (Eds.), Worry & psychological disorders: Theory, assessment & treatment (pp ). Chichester: John Wiley and Sons, Ltd. (Overview of a cognitive model of IU) Koerner, N., & Dugas, M. J. (2008). An investigation of appraisals in individuals vulnerable to excessive worry: The role of intolerance of uncertainty. Cognitive Therapy and Research, 32, (Experimental paper looking at appraisals by those with high IU) Ladouceur, R., Gosselin, P., & Dugas, M. J. (2000). Experimental manipulation of intolerance of uncertainty: a study of a theoretical model of worry. Behaviour Research and Therapy, 38, Meeten, F., Dash, S., Scarlet, A. & Davey, Graham (2012). Investigating the effect of intolerance of uncertainty on catastrophic worry and mood. Behaviour Research and Therapy, 50 (11). pp ISSN X. Wells, A. (1995) Meta-cognition and worry: A cognitive model of generalised anxiety disorder. Behavioural and Cognitive Psychotherapy, 23, Wells, A. (1997). Cognitive Therapy of Anxiety Disorders: A practice manual and conceptual guide. Chichester, UK: Wiley. Wells, A. (2006). Metacognitive Therapy for Worry and Generalized Anxiety Disorder. In: G.C.L. Davey & A. Wells (Eds.). Worry and Psychological Disorders: Assessment and Treatment. Chichester, UK: Wiley. (Very clear overview of the metacognitive model of GAD and worry)