Cognitive Interventions

Cognitive restructuring can be used to modify dysfunctional cognitions relevant to the anxiety disorder (e.g., faulty appraisals of threat from intrusive thoughts), as well as those relevant to depression (e.g., "I can't ever be happy again"). Thus, patients learn to use the same skills to reduce both their depressive and anxious thinking (Abramowitz, 2004). Individuals with anxiety problems often overestimate the probability and severity of various threats (risks), and underestimate their ability to cope with them (resources) (Beck & Emery, 1985). Thus, the goal of cognitive restructuring is to help patients to develop healthier and more evidence-based thoughts—to help them to adjust the imbalance between perceived risk and resource (Beck & Emery, 1985).

Specific cognitive distortions may need to be identified and challenged through cognitive restructuring. For example, common distortions in GAD include "probability overestimation" and "catastrophic thinking." To counter catastrophic thoughts, patients are asked to imagine the worst possible feared outcome actually happening, then to evaluate critically the severity of the impact of the event. Cognitive restructuring in the treatment of comorbid depression and PTSD may need to target the negative appraisals of the traumatic event and its sequelae, which lead to a sense of recurrent threat.

Cognitive interventions can also be applied to the core beliefs that underlie depression, anxiety disorders, or both. For example, standard cognitive restructuring interventions can be applied to test the validity of (and modify) beliefs about one's inflated responsibility for intrusive thoughts, thought-action fusion, perfectionism, and excessive concern over mistakes that may be present in patients with OCD. Cognitive restructuring may be needed to address dysfunctional beliefs in patients with PTSD regarding the dangerousness of the world and their capability, acceptability, or survivability. Finally, cognitive restructuring may also need to address the positive or negative beliefs about worry that are present in patients with GAD, as well as the core beliefs that they have little or no control over perceived threats.

Finally, individuals with comorbid disorders may present with a number of problems related to interpersonal or occupational functioning. Therapy may need to include problem-solving interventions designed to identify a problem, generate a list of potential solutions, choose from the list of alter natives, and implement the solution to the problem (D'Zurilla & Nezu, 2001).

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