Academic journal article Journal of Cognitive Psychotherapy

Cognitive Case Conceptualization and Treatment of Anxiety Disorders: Implications of the Looming Vulnerability Model

Academic journal article Journal of Cognitive Psychotherapy

Cognitive Case Conceptualization and Treatment of Anxiety Disorders: Implications of the Looming Vulnerability Model

Article excerpt

This article describes an approach to cognitive case conceptualization and treatment that is based on the "looming vulnerability" model of anxiety. The model assumes that much of what produces anxiety for people in everyday life, as well as in cases of pathological anxiety, is "looming" from their point of reference, or changing dynamically and step-by-step in time to become increasingly risky. That is, they have a "sense of looming vulnerability" to threat-perceptions of threat as moving toward an endpoint or rapidly rising in risk. Anxious individuals manifest biases in their primary cognitive appraisals (a painful sense that perceived threats are rapidly approaching, changing, or escalating in risk), and in consequence, feel "pressed" to urgently cope with or neutralize the looming threat. The net result of their sense of urgency is that they often select maladaptive, rigid coping strategies (e.g., avoidance and escape) and underestimate their personal efficacy to effectively deal with the oncoming dynamic threats (i.e., biased secondary appraisal). We suggest that anxiety is often based on dynamic, story-like scripts, called progressive threat scripts. The present article identifies several ways that cognitive therapists can conceptualize, identify, and modify features of patients' mental simulations of present or developing threat (i.e., distance, motion, speed, and perspective). The article also addresses several features of anxious patients' response to threat that are relevant to cognitive case conceptualization and treatment (i.e., generating alternative simulations, time structuring, proactive coping, and the enhancement of dynamic personal efficacy for dealing with rapidly rising risk).

Anxiety disorders continue to be the most common mental disorder in the United States, with an annual prevalence rate of 15%-17% of the adult population (Kessler et al., 1994; Regier et al., 1993). Moreover, anxiety disorders are the most expensive mental disorders in the United States, costing an estimated $46 billion dollars in 1990 alone (Rovner, 1993). Consequently, it should not be surprising that the experience of pathological anxiety is pervasive in the psychological literature. Documented cases of anxiety disorder or "neurosis " appear in the writings of Freud (1919/1959), Sullivan (1953), and Kernberg (1976), to mention a few. Further, anxiety is awarded a central role in theories of attachment (Bowlby, 1973), social cognition (e.g., Fiske & Taylor, 1991), and coping (Lazarus & Folkman, 1984), as well as in a plethora of cognitive models of information processing (e.g., Kendall & Ingram, 1987; Mathews & MacLeod, 1985). As we address later, anxiety can play a central role in the therapeutic process itself and is often accorded causal status in the behavior of clients who resist therapeutic change (e.g., Freud, 1919/1959).

Traditionally, behavior therapy has been the treatment of choice for anxiety disorders (e.g., Smith & Glass, 1977), whereas outcome research on global therapies for anxiety disorders (e.g., psychodynamic, client-centered) has failed to show consistent efficacy, above and beyond that produced by placebo therapy or nothing at all (Greenberg, Elliott, & Lietaer, 1994; Prochaska & Norcross, 1994). While behavioral therapies have demonstrated efficacy in the treatment of specific phobias, the results of these therapies appear less promising when a specific feared stimulus cannot be identified. For example, behavioral therapy is considerably less effective for treating agoraphobia (O'Sullivan & Marks, 1991), generalized anxiety disorder (Barlow & Beck, 1984; Chambless & Gillis, 1993), panic disorder (e.g., Clark, 1993), and obsessive compulsive disorder (e.g., Rachman, 1997, 1985). Furthermore, researchers have found that a combination of cognitive therapy and behavior therapy is more effective in the treatment of panic disorder with and without agoraphobia (Barlow, Craske, Cerny, & Klosko, 1989; Clark, 1993), generalized anxiety disorder (Borkovec etal. …

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