Unwanted Mental Intrusions in Anxiety Disorders: A Modified Cognitive-Behavioral Approach
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1 Unwanted Mental Intrusions in Anxiety Disorders: A Modified Cognitive-Behavioral Approach David A. Clark, PhD University of New Brunswick, Canada ADAA Conference, April 12, 2012
2 Unwanted Intrusive Thoughts Repetitive thoughts, images or impulses that are unacceptable and/or unwanted. They interrupt an ongoing activity, are attributed to an internal origin, and are difficult to control. - Rachman (1981)
3 Clinical Examples of Intrusions Obsessional intrusion- repugnant aggressive, sexual, religious thoughts, mental contamination Worry intrusion- unintended occurrence of anticipatory thought related to threat of current concern Trauma-related intrusion- sudden reminder of past traumatic experience
4 Characteristics of Unwanted Intrusive Thoughts A distinct identifiable cognitive event Unwanted, unintended, & recurrent Interrupts the flow of thought Interferes in task performance Associated with negative affect Difficult to control
5 Unwanted Intrusions: A Nuanced Phenomena Strong connection to normality Occurrence trumps content Contextually bound cognitions Excessive, irrational, ego-dystonic Impervious to effortful control
6 Normal Intrusions: The Good, the Bad and the Ugly 67% of thoughts deal with everyday life concerns (the good) 18% of thoughts may be unacceptable and uncomfortable (the bad) 13% of thoughts were rated as out of character or downright shocking (the ugly) - Klinger & Cox ( )
7 Challenge for Standard CBT & ERP Context-driven nature of intrusions Misdirected focus on intrusion content rather than process High distress intolerance Poor homework compliance
8 Treating Intrusions: Three Facets Context (triggers) Metacognition (appraisals) Mental Control
9 UIT Context Assessment and Treatment
10 Triggers & Context: Internal/external origins, spontaneous & unintended
11 Assessing UITs Retrospective self-report questionnaires Daily self-monitoring Symptom provocation Imaginal & role play simulation Electronic cueing (??)
12 Treatment: Normalization Refocus psychoeducation (appraisal not content) Select a normal intrusion toxify a nonrecurrent, negative thought Select the problematic UIT Develop de-toxification plan
13 UIT Appraisal Treatment Considerations
14 Metacognition & Intrusions Metacognitive knowledge refers to the beliefs and theories people have about their thinking, whereas metacognitive experiences are the context-specific appraisals and feelings individuals have of their mental status. - Wells (2009) Metacognitive Theory for Anxiety and Depression
15 Faulty Appraisals & Intrusions Overestimated Threat Intolerance of Uncertainty Inflated Responsibility Overimportance of Thoughts Need for Mental Control Emotional Reasoning
16 Cognitive Restructuring of Appraisal Beliefs Focus on real-life intrusion experiences (appraisals gone wrong) Identify faulty evaluative process and underlying belief Use evidence gathering and consequences to challenge belief Generate alternative benign evaluation Obtain experiential evidence of catastrophic vs. benign interpretation
17
18 Pathological Mental Control- Clinical Illustration Thinking About Breathing Mental Control Effort Intrusions increase; inability to distract; heightened anxiety Appraisals of Control Failure
19 Mental Control Strategies Cognitive distraction or thought replacement Rationalization and self-reassurance Self-criticism or punishment Reassurance seeking from others Thought stopping Behavioral distraction Attentive thinking, analyzing the thought Cognitive restructuring Do nothing
20 Relinquishing Control Demonstrate futility of control ( white bear ) Introduce overt & covert response prevention Practice intentional mental exposure ( thought satiation ) Capitalize on spontaneous intrusions (situational exposure) Distance; nonjudgmental acceptance
21 Summary Strange thoughts are normal, safe Meaning modulates emotion Effortful control is counterproductive Observe, accept, distract
22 Disclosures Cognitive Therapy of Anxiety Disorders (Guilford) The Anxiety and Worry Workbook (Guilford) Overcoming Obsessive Thoughts (New Harbinger) Cognitive-Behavioral Therapy for OCD (Guilford) Intrusive Thoughts in Clinical Disorders (Guilford)
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