Commonalities In The Treatment Of Mood And Anxiety Disorders

In treating comorbid conditions, clinicians need to consider the degree to which strategies used in one problem area may be utilized in the treatment of other areas of distress. This approach not only holds the potential for more efficient treatment but also may be useful for honing a patient's own skills in applying principles of treatment to new problem areas—skills that are important for relapse prevention efforts.

Cognitive interventions are, of course, ubiquitous in empirically supported treatments for mood and anxiety disorders. In both anxiety and mood disorders, cognitive interventions include, for example, informational interventions, Socratic questioning, self-monitoring, and behavioral experiments (J. S. Beck, 1995). In general, for the anxiety disorders, these strategies often target the overestimations of the probability or degree of catastrophe of feared outcomes (cf. Barlow & Craske, 2000; Hope, Heimberg, Juster, & Turk, 2000). Moreover, in our experience, the content of cognitions encountered in depression is similar to that encountered in social phobia. In both disorders, restructuring efforts are likely to target beliefs about personal inadequacy and unlovability, perhaps related to self-imposed perfectionistic standards. Hence, because of this shared content of dysfunctional thoughts, cognitive interventions for one disorder may easily be extended to the other.

Compared to comorbid social phobia, cognitive interventions for panic disorder, although using the same strategies, are likely to involve cognitive content that is more distinct from depression. In panic disorder, core dysfunctional cognitions focus on catastrophic misinterpretations of the meaning and consequences of anxiety symptoms ("Am I having a heart attack?"; "What if I lose control?"; "I am going to be humiliated"; for recent study, see Raffa, White, & Barlow, 2004). Nonetheless, the negative and self-punitive cognitions that follow the avoidance of desired activities ("I can't believe I didn't go; I am such a loser"; "I just can't do things that others do") appear to be more similar to the cognitive content frequently encountered in depression (e.g., Beck, Rush, Shaw, & Emery, 1987).

In the treatment of comorbid conditions, clinicians can teach patients the method, style, and results of cognitive restructuring, then apply it to the symptom domains identified as most important for a coherent ordering of treatment, while keeping in mind the complications brought by the comor-bid condition. For example, Otto and Gould (1996) have suggested that if panic disorder is selected as a primary focus of treatment, three areas for cognitive restructuring are important in addressing the impact of depression on this treatment. First, as we discuss further below, depression is likely to enhance fears of anxiety sensations and negative evaluations of others (Otto et al., 1995; Wilson & Rapee, 2005). Accordingly, during presentation of the model of the disorder, we believe the mood-state-dependent aspects of anxiogenic thoughts should be emphasized. Patients need to be informed of the degree to which negative thoughts "feel truer" when affect is strong; that is, worries about negative outcomes in the future feel as if they will come true, concerns about negative evaluations from others feel more like they are happening, and worries about health or the meaning of symptoms feel more dire when depression is present. Patients need to be made aware of this phenomenon and to be vigilant, as part of cognitive restructuring efforts, to challenging these thoughts when mood is low.

Second, patients should be prepared for their tendency to evaluate progress negatively (e.g., "This isn't working; I am not like other patients that can get better; I am failing"), and to practice recognizing and confronting these cognitions before they encounter them during exposure assignments. In particular, we believe it is important for therapists to troubleshoot homework assignments and, when depression is present, to review explicitly common negative reactions to progress that may occur during the week between sessions. The aim is to help patients identify these cognitions (e.g., "My therapist told me I might be thinking that") as a way to nullify the emotional impact of these thoughts and to occasion cognitive restructuring efforts.

Third, due to motivational issues, patients may require additional attention to homework adherence, including perhaps clearer and more objec tive self-monitoring of progress and cognitive restructuring interventions focused on motivation for homework completion. This involves more troubleshooting relative to homework assignments when they are made, as well as stronger efforts to acknowledge progress when it occurs. Again, we recommend that therapists rehearse common negative motivational responses when assigning homework (e.g., "Given that your mood is low, what are you going to think when you do your exposure practices this week?") and rehearse alternative responses (e.g., "When you are at home, feeling like exposure practice is pointless, what do you think might help you?"). For patients with strong impairments in motivation, we make all assignments especially stepwise (with multiple small steps geared toward success) and attend to ways we can chain together behaviors to place patients in the right context for an exposure (e.g., the first step is to get patients out of the house and active, so that exposure assignments seem relevant). This process is aided by the natural synergy between emphasis on stepwise exposure to feared situations and events in the anxiety disorders and its counterpart in behavioral activation treatments for depression.

Behavioral activation approaches to depression emphasize the role of depression-related inactivity and withdrawal as maladaptive coping strategies that isolate individuals from opportunities for positive affect and propagate depression (for review, see Hopko, Lejuez, Ruggiero, & Eifert, 2003). Accordingly, treatment emphasizes step-by-step reemergence into meaningful work, social, and leisure activities. A focus on the return to meaningful activities is synergistic with the goals of exposure interventions, although when applied to the treatment of anxiety disorders, greater emphasis is devoted to teaching strategies to manage anxious apprehension and to accept the anxious affect likely to be evoked as part of exposure (see Otto, Powers, & Fischman, 2005). The potential confluence of goals for behavioral activation interventions is nicely illustrated in a case example by Hopko, Lejuez, and Hopko (2004), who applied behavioral activation interventions in a 10-session, stepwise exposure format to patients with both depression and panic disorder.

When a therapist arranges treatment to focus first on depression, we encourage attention to three sources of negative affect that are likely to be driven by a comorbid anxiety disorder. First, fears of anxiety sensations or avoided situations (social or agoraphobic) make participation in a wide variety of activities especially difficult (with frequent distress and/or avoidance). Second, self-perceived failures in these situations/activities (at times defined simply by the reoccurrence of anxiety and avoidance) may intensify negative self-evaluations and depressed affect, and compromise the positive affect that would otherwise be generated by these activities. Third, cognitive responses to social and role failures due to anxiety and avoidance may intensify patients core beliefs that they are flawed or incompetent. Accordingly, activity assignments for depression may require careful troubleshooting to assess the degree to which anxiety and avoidance will be elicited, and adoption of a stepwise exposure approach, with anxiety-specific cognitive preparation (e.g., Barlow & Craske, 2000; Hope et al., 2000; Otto, Jones, Craske, & Barlow, 1996) to address these issues proactively. The degree to which anxiety and panic responses are directly punishing to patients and retard their efforts to return to enjoyable activities (i.e., the anxiety makes potentially enjoyable events feel like failure experiences) may be one reason why anxiety disorders appear strongly to reduce the efficacy of treatments for major depression (see below).

The degree to which emotional acceptance is promoted by CBT is an additional common factor that deserves attention in the treatment of comorbid conditions. For example, study of the relapse prevention effects of cognitive therapy for depression suggests that the degree to which these techniques enhance metacognitive awareness (a cognitive set in which negative thoughts and emotions are viewed as passing mental events rather than characteristics of the self; e.g., "I am my affect") is linked to a reduced risk of relapse (Teasdale et al., 2002). Likewise, at their core, exposure-based treatments for anxiety disorders, and panic disorder in particular, provide training to reduce fears of anxiety sensations and to respond adaptively despite the presence of these sensations (Otto et al., 2005). Patients in exposure-based treatments learn to respond differently to anxiety sensations; specifically, to learn to do nothing special to manage the sensations (stopping all the effort to avoid, protect against, or otherwise stop emotional sensations, and instead learning to become more comfortable with this affect). In panic disorder in particular, when patients learn to react differently to anxiety sensations, the regular evocation of panic attacks ceases. Indeed, this sort of promotion of emotional acceptance/tolerance may be a general factor in treatment that helps patients break the link between negative affect and dysfunctional responses to that affect (e.g., avoidance in anxiety disorders, and inactivity in depression) that propagates disorders (Barlow, Allen, & Choate, 2005). As discussed by Barlow et al., therapeutic packages that emphasize the replacement of the action tendencies driven by negative affect with actions consistent with alternative emotions have shown efficacy for a variety of disorders, including depression, anxiety disorders, and borderline personality disorder. This conceptualization is also consistent with "acceptance" models of change that emphasize adaptive pursuit of goals regardless of the presence of aversive thoughts or emotions (see Hayes, Strosahl, & Wilson, 1999). Accordingly, in the treatment of comorbid conditions, clinicians may want to underscore this ability. Working to extend this communality across the affective patterns under treatment (extending emotional acceptance skills that patients learn from exposure also to responses to the negative affect of depression) may prove useful for efficient treatment of comorbid conditions and/or provide broader skills for relapse prevention.

At a clinical level, it accordingly seems important for cognitive therapists to help patients at a level beyond detection and correction of specific cognitive errors: helping them to develop a more general capacity to take their thoughts less seriously, while working to become more comfortable with their experience of affect in the context of working to meet personal goals (e.g., completing events that provide a sense of both mastery and pleasure in relation to depression, or meeting goals in social situations rather than being vigilant to symptoms or fears about evaluations from others).

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