Why do negative thoughts and beliefs persist

If the world is not as dangerous as anxiety disorder patients assume, why do they not notice this and correct their thinking? For many patients with chronic anxiety disorders, the persistence of their fears can seem strangely irrational, at least at first glance. Consider, for example, panic disorder patients who think during their panic attacks that they are having a heart attack. Before they come for treatment they may have had several thousand panic attacks, in each one of which they thought they were dying, but they are not dead. Despite what might appear to an outsider as stunning disconfirmation of their belief that a panic attack can kill, their thinking has not changed.

Several factors that appear to prevent patients from changing their negative thinking are outlined below. Such factors are important because reversing them is likely to be a particularly efficient way of treating anxiety disorders.

Avoidance, escape, and safety-seeking behaviours

Early conditioning theorists identified avoidance of, and escape from, feared stimuli as important factors in the maintenance of anxiety disorders. It is easy to see how avoidance of a feared situation (e.g. a supermarket for an agoraphobic) or escape from the situation before a feared event (e.g. a panic attack) occurs could prevent phobics from disconfirming their fears. However, situational avoidance/escape is not so obviously relevant to non-phobic anxiety and some phobics (especially those with social phobia) regularly endure feared situations without marked improvement in their fears. Salkovskis (18) introduced the concept of in-situation safety behaviours to deal with this problem. In particular, Salkovskis suggested that while in feared situations most patients engage in a variety of (often subtle) behaviours that are intended to prevent, or minimize, a feared outcome. For example, cardiac concerned panic disorder patients may sit down, rest, and slow down their breathing during attacks and believe, erroneously, that performing these safety behaviours is the reason why they did not die. Experimental studies have confirmed that (a) anxious patients engage in safety behaviours (!9> while in feared situations, and (b) dropping these behaviours facilitates fear reduction. (2 ,21>

Recent work(22> has highlighted several other important features of safety behaviours. First, although termed 'behaviours', many are internal mental processes. For example, patients with social phobia who are worried that what they say may not make sense and will sound stupid, often report memorizing what they have said and comparing it with what they are about to say, whilst speaking. If everything goes well, patients are likely to think 'It only went well because I did all the memorizing and checking; if I had just been myself people would have realized how stupid I was'. In this way their basic fear persists. Second, it is common for patients to engage in a large number of different safety behaviours while in a feared situation. Table 2 illustrates this point by summarizing the safety behaviours used by a patient who had a fear of blushing, especially while talking to men whom she thought other people would think were attractive. Third, safety behaviours can create some of the symptoms that patients fear. For example, responding to a feeling of breathlessness in panic attacks by breathing more quickly and deeply (hyperventilating) can enhance the feeling of being short of breath. Similarly, post-traumatic stress disorder patients who are concerned that unwanted intrusive recollections of the trauma mean they are going mad often try hard to suppress such recollections. Unfortunately, active suppression increases the probability that the intrusion will occur. (23> Fourth, some safety behaviours can draw other people's attention to problems that patients wish to hide. For example, a secretary who covered her face with her arms whenever she felt she was blushing discovered that colleagues in her office were much more likely to look at her when she did this than when she simply blushed. Finally, some safety behaviours influence other people in a way that tends to maintain the problem. For example, the tendency of social phobics to monitor continually what they have said, and how they think they come across, often makes them appear distant and preoccupied. Other people can interpret this as a sign that the phobic does not like them and, as a consequence, they respond to the phobic in a less warm and friendly fashion.

Table 2 Safety behaviours associated with a fear of blushing

Attentional deployment

Selective attention plays an important role in maintaining some anxiety disorders. Patients with panic disorder or hypochondriasis fear certain bodily sensations and symptoms, believing they indicate the presence of a serious physical disorder (heart attack, cardiac disease, cancer, etc.). Such patients have often had several medical investigations that indicate they do not have the physical illness(es) they fear, but they are not convinced. One reason appears to be that their fears lead them to focus attention on relevant parts of their bodies and, as a consequence of this attentional deployment, they become aware of benign bodily sensations that other people do not notice.(25 The presence of such sensations is then taken by the patient as evidence that a serious physical illness has been missed. (Hypochondriasis is classified as a somatoform disorder in DSM-IV(1.0) and as a somatization disorder in ICD-10. (25> However, it has many features in common with anxiety disorders and can be conceptualized as such for the purposes of psychological treatment. (26))

Social phobia appears to be associated with two attentional biases. First, when in feared social situations, patients with social phobia report becoming highly self-focused, constantly monitoring how they think and feel they are coming across, and paying less attention to other people. Reduced processing of other people means that social phobics have less chance to observe other people's responses in detail and, therefore, are unlikely to collect from other people's reactions information that would help them to see that they generally come across more positively than they think. (2Z> Second, there is some evidence that when social phobics do focus on other people, they are particularly good at detecting negative reactions (28> and are poor at detecting positive reactions.

Spontaneously occurring images

Spontaneously occurring images are common in anxiety disorders and also appear to play a role in maintenance. Patients with social phobia often report 'observer-perspective' images in which they see themselves as if viewed from outside. (29> Unfortunately, in their images they do not see what a true observer would see, but rather their fears visualized. For example, a teacher who was anxious about talking with colleagues in coffee breaks noticed that before speaking she felt tense around her lips. The tension would trigger an image in which she saw herself with a twisted and contorted mouth, looking like 'the village idiot'. At that moment, she was convinced everyone else thought she was stupid. Negative images are also used as information in other anxiety disorders. For example, obsessional patients who have images of committing a repugnant act (e.g. stabbing one's child) take the occurrence of the image as evidence that they are in danger of performing the act. Similarly, patients with post-traumatic stress disorder report that flashbacks increase the perceived likelihood of a future trauma.

Emotional reasoning

A further source of misleading information that can enhance patients' perception of danger is anxiety itself. (30) For example, social phobics often think they look as anxious as they feel but in general this is not the case. Similarly, generalized anxiety disorder patients often take feeling on edge as a sign that something bad is about to happen.

Memory processes

Some anxiety disorders are associated with a tendency for the selective recall of information that would appear to confirm the patient's worst fears. For example, high socially anxious individuals selectively recall negative information about the way they think they have appeared to others in the past when anticipating a stressful social interaction.^,1' Similarly, patients with hypochondriasis selectively recall illness-related information.

Rumination

P>Anxious patients often spend protracted periods of time ruminating about negative things that could happen in the future and about how bad they would be. They may also ruminate about things that they feel have gone wrong in the past. Studies by Davey and Matchett(32) indicate that such rumination can enhance fear. There are several ways in which rumination might operate. First, thinking about an event may directly increase its subjective probability. Second, selectively focusing on past negative events, feelings, and impressions may further enhance the perceived likelihood of future danger. Third, rumination is rarely focused on constructively processing perceived threats, but instead often seems to elaborate the threats or make them more abstract and hence difficult to deal with. For example, patients with post-traumatic stress disorder often ask themselves 'Could I have done something different?' during their traumatic event without thinking through in detail what their alternative options might have been, and how feasible they would have been at the time.

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