Deze samenvatting is gebaseerd op het studiejaar 2013-2014.

Lecture 1

The title of the book consists of 2 descriptions: ‘cognitive behavioural’ and ‘transdiagnostic’. The reason why we focus on ‘cognitive behavioural’ is because most research has been done in this area. The book only focusses on axis 1 disorders, not on axis 2, because of the same reason. We also focus on maintaining factors of psychopathology, not on etiological factors. The other factor of the book focusses on is the ‘transdiagnostic’ approach. The number of disorders has increased over the years, right now there are almost 300 different diagnosis according to the DSM. Research has been aimed at coming up with very specific models for different disorders, for example: People with a fear of flying are being explained by different learning models than people with a fear of spiders and their treatments are also different. You can distinguish Splitters and Lumpers. Splitters think about disorders in their diversity, they say that there are many types of anxiety disorders and they split all these specific types. Lumpers are the people who throw it all on one big lump, they look at similarities and underlying processes. For example: they look at perfectionism within different disorders or they look at broader categories. Because of these lumpers, the transdiagnostic approach exists.

Transdiagnostic approach
Why is a transdiagnostic approach useful? People may classify for more than one diagnosis at the same time, In fact, most people do. For example: people with a specific type of anxiety disorder have a bigger chance of also having another anxiety disorder. Furthermore, people may also qualify for more diagnosis during their entire life, sequentially. For example: a person who has anorexia may develop bulimia afterwards. So the most important factor for why a transdiagnostic approach is useful, is because there is a high rate of comorbidity across disorders. The other advantage is the phenomenon of group therapy: because there are so many people who have the same underlying problem, it is easy to address these problems in group therapy. This is cast-effective and for the therapist it’s easier to focus. The third advantage of a transdiagnostic approach is the advantage of scientific progress: the transfer of knowledge can move very quickly between fields and the patients will profit from that. One of the disadvantages is that there are differences across disorders in presentation. However, the content of the disorders may differ, but the underlying processes are the same. So the point here is that the content doesn’t really matter, because you’re treating the process.
The book describes a lot of empirical studies. They use four criteria for whether there is a transdiagnostic process. The first criteria considers the number of studies that have been done and the independence of research groups. The second criteria looks at the psychometrically validated instruments for diagnosis. The third criteria looks at convergent evidence, so they look if it’s from more than one paradigm, and the fourth criteria makes sure that the study is methodologically strong, so that it has used a control group and that the statistical power is high.
The transdiagnostic approach focusses on common processes (e.g. intrusive memories, rumination, avoidance). The book distinguishes the following processes:
- Attentional processes (paying attention to one thing and not to another)
- Memory processes (encoding and retrieval of information and in both there can be biases)
- Reasoning processes (how do you come to a certain conclusion, you don’t use all the information)
- Thought processes (white bear experiment; don’t think about a white bear, and all you can think about is the white bear)
- Behavioural processes (e.g. avoidance).

Autobiographical memory task
In an autobiographical memory task, they present the cue word ‘Happy’. You have to come up with a specific memory associated with the word happy, and this memory has to be specific in time, location en it shouldn’t last longer than a day. People from the general population would say things like ‘my last birthday party’ or ‘the birth of my child’. However, people with PTSD would say ‘I’m never happy’ or ‘In het summer of ’76 when I stayed with my grandparents’. These situations are not specific and this phenomenon regards to overgeneral memory. With specific memories you would feel happy or sad again thinking about those memories and overgeneral memory makes sure that you don’t feel many emotions anymore, so your life is very flat.

Exam
The exam consists of 6 open questions and during the lecture we discussed different forms of questions. Examples of questions asked during the exam are listed below.

• Describe and explain theory & processes described. Example; what is attentional bias?
• Which paradigms are used to measure these processes? Example; attention bias is explained by a dot-probe task.
• Is a certain process a (definite, possible, etc.) a transdiagnostic process?
• If not, explain differences between disorders.
• Provide examples of described processes in a specific disorders? Example; what would a patient say, what would it look like? Make sure that when they ask for an example, you actually give an example!
• Explain how these processes contribute to the maintenance of a disorder

Lecture 2

In many disorders people are experiencing an attention bias. Biases in attention, interpretation en memory have a reciprocal relationship with many disorders. Characteristics and components of attention bias consist of directing attention away from the task at hand (the priority task), problems in non-intentional (automatic) attention, there are individual differences (also between men and women) and there is a difficulty to re-direct attention or to disengage attention. During the lecture they showed a video in which a hot girl was walking across the street, and all the men were looking at her. Most of them looked twice, the first time because it was automatic and the second time was more strategic: it was interesting for them to look at her.
There are important stimuli that attract all peoples attention (for example something very loud or something that moves very quickly), but some features are learned and don’t have to be very functional. The concept of binocular rivalry describes the fact that there is always competition between stimuli that will win. When people were shown a picture of a house and a picture of a face, in which you can’t see both at the same time, it turned out that most people see the face 70% of the time, but that people with social anxiety disorder see the face all the time. So even though those people actually see the same, the things that they process are very different.  A learned fear could also lead to seeing the face more.

Illustration panic disorder
If you think that you will die from a heart attack or that you are afraid of that, then you can get a selective attention for stimuli that are related to heart attacks. When those people focus extra on their heart, their heart will feel different and threat appraisal increases. They interpreted these feelings as dangerous and then, because of the anxiety, they get all kind of physiological responses (like heart palpitations), which motivates them to focus their attention even more on those stimuli. So they misinterpreted feelings that actually aren’t dangerous, which makes them even more prone to stimuli that are consistent with their anxiety. This can lead them to avoid certain behaviours (check things all the time, use medication, only go shopping with a partner). So the selective attention is both the cause and the maintaining factor of the panic. The cognitive motivational view says that when is a stimulus is represented (heartbeat), that the valence evaluation systems will be activated. When this system interprets it as dangerous (high threat) then it will interrupt current goals and it will orient to the threat stimuli. However, when the threat is low it just continues with pursuing its current goals.

How to measure attentional processes
It is important to measure the attentional processes before you can say anything about that in regard to different disorders. One way to do this is to look for interference effects. A test that has often been used is the Stroop-test: color-naming interference task. People are presented with anxiety-related words (like spider) and with neutral words in different colours. They have to ignore the type of word, they just have to name the colour in which the word is presented. It turned out that people with a fear of spiders are slower in telling the colour of the word with spider-related words than when the words were neutral. This could be true for all other kind of anxieties. However, here the people could actually read the words. When the same tasks was done but the participants couldn’t actually read to words (because they were presented to them subliminal), it turned out that anxious people do slow down to threat words, but that they reported they had not seen any words at all.
When you want to measure attentional biases in anxiety disorders, it’s important to look at the discriminative power, where you compare patients with a control group. Research has shown that people with social phobia tend to slow down to social evaluation stimuli, people with PTSS slow down to stimuli that are related to their trauma en people with hypochondriasis slow down to words like cancer or other deadly diseases. So there are also very specific effects. Furthermore, you have to consider presenting the words suboptimal or subliminal. For subliminal tests you could use the danger- premium on speed-trait x state. Predictive validity is very important when doing tests.

Predictive validity 1
They used a subliminal Stroop task, where they used general threat words (like danger, war, attack). They selected women who were waiting for colposcopy, so they actually knew that a part of the people would have cancer. Those people took the test before they knew they had cancer or not. Then after getting the diagnosis, they measured those people again to see what the effect was of knowing the diagnosis. It turned out there was an interference effect: this was the single best predictor of elicited emotional distress of getting the diagnosis. So apparently there might be individual differences (some might give priority to negative information) and when something negative happens, some people may look at the negative aspects of that event while other may look at the positive aspects of the negative event.
 
Predictive validity 2
In the second research they used a masked and an unmasked Stroop task and the participants (undergraduates) were given panic-related threat words (like palpitation and stroke). The participants got a cap before their mouth in which they had to breath. At first you think that nothing is happening to you, but it takes some time for the CO2 to enter your longs and your brains. Then the whole world is starting to turn and most people get really terrified. The CO2 inhalation only ends when it has left your body. It’s the uncontrollability that makes them very fearful. Then they measured the amount of distress and what predicted for the attentional bias. It turned out that the interference effect of the attentional bias predicted emotional responding over and above anxiety sensitivity index, so that shows that attentional bias could also be a causal aspect.

It’s also possible to have an attentional bias concerning appetitive cues, but here the bias is directed toward something you like. Studies with alcoholic cues in people with an addiction show that abusers have a huge attentional bias towards alcohol words or alcohol pictures. Controls show this bias as well, but much less. The interesting about alcohol is that it’s not only the case that people have a selective attention for those cues, but as soon as you’ve had one drink your capacity to control your drinking is reduced on the short and on the long term. People also vary concerning attentional control, some people have problems with directing their attention and this can be a predictor of different psychological disorders.

In one study, people were presented with faces (angry, fearful, happy) and these faces were followed by a colour filter. People had to colourname the filter and ignore the face stimuli. If your problem has something to do with negativity or fearfulness, than you would be more distracted by those faces. In this study they looked at people with low anxiety and high anxiety. It turned out that if you are both trait anxious and you have not much attentional control, then you have a high risk of getting an attentional bias. However, this does not count for people who are trait anxious and have much attentional control. This means that the model the cognitive model is moderated by attentional control.

Attentional bias and obese (in children)
In one study they presented high calorized and low calorized words in a stroop interference task. It turned out that controls would prefer high calorized food a little, but that obese children don’t show an attentional bias for high calorized food at all. One thing was that the neutral stimuli and high calorized food stimuli were mixed. It turned that the participants were able to distract themselves from the urge to go for the high calorized food. When the stimuli were presented to them in a blocked forum (so multiple high calorized food stimuli after each other), obese people did show the attentional bias. So apparently, they can resist one stimuli, but there is a point at which they cannot resist the bias anymore.
Clinical interventions to enhance strategic control
There are two types of interventions that can be used and one of them is Attentional training, a method that is often used for treating social phobia. These are clinical interventions to reduce impact of the attentional bias. For example: we can’t reduce the blushing that someone is experiencing, but we can learn them to continue the task at hand even when they are blushing. Because when your working memory is occupied by the thoughts about the blushing, then there isn’t much room left for doing another task. So this method helps as a copingstrategy to learn those people how to continue their task and it turned out that it actually reduces their blushing as well. Another type of intervention is mindfulness and this one is especially relevant in the context of depression. With mindfulness you’re not trying to control your thoughts, but you learn to accept them and just let them be.

Critical issue
There is one critical issue: does the interference effect indeed reflect attentional bias? Perhaps people are slowing down because they try to avoid information or perhaps it’s just that the particular stimuli have a particular startle effect because of familiarity or the effect of rumination. For that reason some people say that the dot probe task would be better to check this assumption. During the dot probe task, you have to say as quickly as possible whether you think it is an E or an F. But before you see these letters, you see two words above each other (for example spider or chair). People who are afraid of spiders turn out to react slower when the letter is not presented at the location of the disturbing word. This task can also be done with faces. You also have a visual dot probe task, in which images are used.
Temporal unfolding of the attentional bias can be tested by lengthening the time that the stimulus is presented. That way you can measure if people turn their attention towards the stimuli or away from the stimuli. In anxious people, it turned out that the higher the fear, the stronger the interference effect. But, when the stimulus is showed even longer, you see an attentional avoidance effect for that same stimuli. When you look at addiction, abusers do keep their attention on the drug-related stimuli, because they have no motivation to move their attention away. It turns out that when you present the stimuli suboptimal to abusers, there is no attentional bias, but the longer you present the stimuli, the more they want to move towards them.
In research on attention bias and eating disorders, they found that eatingdisorder patients fixate on beautiful body parts of other people, while the control group fixated most on the beautiful body parts of themselves and the most ugly body parts of other people. There is a selective attention bias in people with anxiety disorders. They have an urge to avoid stimuli, which leads to selective attention and a quick and frequent detection of threat stimuli, which in turn leads to avoidance. People with an addiction also have selective attention. Addictive people have an urge to approach, which leads to selective attention of stimuli (drug), which leads to quick and frequent detection of that wanted stimuli. This detection leads to craving, a feeling of really wanting and needing the drug, which in turn leads to misuse. Other disorders that have an attentional bias are anorexia, OCD and sexual dysfunctions. Also the fear of pain can lead to an attentional bias and is often measured by the dual task paradigm. The reason why they use this task is because visual attention is irrelevant here, because it has something to do with what you feel. That’s why presenting these people with visual stimuli won’t be a good measure. People with depression also have an attentional bias, which is often measured by a dual target rapid visual presentation task.
When you really want to know the causal influence, you need to manipulate the attentional bias. So you need to change the attentional bias and see if it has an impact. Research on this topic has been done using the dot probe task, where the probe was always behind the threat word. That way you could induce a bias for threat into you participants. People were learned to focus their attention on the threatened words and after that they exposed those people to a stress task. They measured the mood before and after the training and it turned out that the training itself had no influence on the mood, but the sensitivity of the task had. People who were trained had a more negative mood following the stress task, so they learned to focus their attention to more negative information. This means that it can be a causal agent. Is it also possible then to reduce the bias? For this study they learned people to redirect their attention away from the disgusted face (in the case of socially anxious students). In this research they used the visual dot probe task and it turned out that this way stress sensitivity could be reduced.

Lecture 3

There are some basic distinctions in memory research, because research can be focussed on episodic memory or on semantic memory. Semantic memory is the memory that is holding specific facts, for example: you know Paris is the capital of France. So this type of memory is more about knowing that, remains often intact and also includes autobiographical facts of life. Episodic memory is the memory concerning recollective experiences (you can re-experience events from your past in detail), mental time travel and remembering when. The episodic memory is more vulnerable to psychopathology. Research can also be focussed on the declarative/explicit memory and the non-declarative/implicit memory. The first one consist of the episodic memory system and the semantic memory system. The second one consists of the procedural memory, so this type of memory is active when you learn how to drive a car, for example. It also consists of the processes conditioning and priming. Priming is the focus of this lecture.
There is mood congruent memory and mood(state) dependent memory. In a mood congruent memory, the memory is congruent with your mood state, so when you are depressed then you have a strong tendency to retrieve memories that are negative. Mood(state) dependent memory concerns a phenomenon in which the retrieval of information is more effective when the emotional state at the time of retrieval is similar to the emotional state at the time of encoding. Thus, the probability of remembering an event can be enhanced by evoking the emotional state experiences during its initial processing. So the congruent part is more about contexts, while the dependent part is more about the mood states itself.
In the book they describe seven types of memory processes across disorders and five of them are important to remember. First you have the explicit selective memory bias, which is about the biases in free recall and recognition for concern-related stimuli and about mood-congruent memory. Second, you have the implicit selective memory bias, which concerns the processes of conceptual/perceptual priming of concern-related information. Then you have the recurrent (involuntary) memory, which is about flashbacks of earlier trauma and about the observer-perspective intrusive images in the context of social anxiety. At last, you have the overgeneral memory and the working memory.

How does memory become dysfunctional?
Before we can look at dysfunctional memory, we have to know more about healthy memory functioning. The self-memory system is a model of Conway et al. about the autobiographical memory base explains several layers of distraction and personal goals. These personal working self-goals are formed from the believes, attitudes and current concerns one has. The goals can be concrete (remember this list of words) or abstract (avoiding unsafe situations). These personal goals determine what type of information will be retrieved or is more active or less active in your long-term memory.  According to this model, there are different levels of information in your autobiographical memory base. The highest level consists of lifetime periods, which are series of general events or short periods of life, for example a relationship theme or a work theme (for example: my time in high school). The next layer consists of general events, like your first date, your first kiss. General events lack sensory perceptual details, because these details are in the event-specific details (which is the lowest level). When all these layers come together, you speak of specific autobiographical memory. Not everyone can walk through this retrieval process accurately, because of their psychopathology.

There are two routes of retrieval from the autobiographical memory, there is the generative retrieval and the direct retrieval. Generative retrieval is a top-down process and is effortful. It is working with an intentional search through the layers of the autobiographical memory knowledge base, starting at more abstract levels of information and ending with sensory-perceptual details. For example: when someone asks you if you have ever been to Paris before (abstract cue), the generative retrieval process makes sure that it can take a while before you have the specific answer. You have to dig into your memory for cues about your visit to Paris; with who did I go, when did I go and where exactly did you go. This can take a while, but when you have finally brought up a memory about you and your boy/girlfriend going to Paris together, you can get very specific memories about that event. Direct retrieval is a bottom-up process and works more automatically. It make sure that there is an automatic activation of the autobiographical memory representation by direct mapping of a specific cue with sensory-perceptual-affective details of episodic information. So this route gets information into your consciousness immediately. For example: for the Paris example, When someone shows you a picture of the Eiffel tower (specific cue), you don’t have to dig any further into longer routes, because the cue was specific enough to immediately bring back all the memories you have about going to Paris. Even though you haven’t seen that picture in a very long time, once you see it again, it brings back all the memories. This effect can also occur with things you smell and it doesn’t only occur for positive memories, but it can also happen for negative memories. For example: people with PTSD only have to look at a photo (from a distressing event) which can cause flashbacks.
Specific vs. overgeneral memories
People who are having an overgeneral memory have a relative inability to come up with memories of specific autobiographical events in response to cue words. There are different forms of overgeneral memory: categorical (you can remember that you’ve been to Amsterdam, but you can’t remember any specific moments), extended (when you see the beach, you can think about your last summer vacation, but you can’t remember any details) an mini history (you know that you have been taught how to drive a car, but you can’t remember where or when you have learned this). Specific memories are personally experienced events, which are tied to a particular place and time (

Studying overgeneral memories (OGM)
We can study OGM by doing the Autobiographical Memory Test (AMT). During this task, participants have thirty seconds to retrieve a specific memory for each cue. They are instructed that a specific memory refers to one particular personally experiences event that happened on a particular day at least one week before today. It is very important to know if the participants understand the instructions! The cues that are presented to the participants are abstract cues like ‘happy’ or ‘rejected’, so they have to dig deep into their memory. Research has been done with the AMT in participants with depression, schizophrenia and a controlgroup. In this sample, they had sixty seconds to think about a specific memory. All the participants got five positive, five negative and five neutral cues. The seriousness of the problem was related to the amount of specific memories that were retrieved. It turned out that the control did really good, but the depressed participants could only retrieve specific information in sixty/seventy percent of the time. Furthermore, the participants with schizophrenia could only retrieve specific memories half the time. So at least OGM was shown in two disorders, which is one indicator that it is, at least in this study, a transdiagnostic process. The question here is whether OGM reflects decreased access (i.e., retrieval failure) to memory contents or decreased availability (encoding plus retrieval failure).

Research has been done about the history of child sexual abuse (CSA), in which OGM is the impaired access to available memory representations. When presenting the people who have been sexually abused with abstract cues, those people did significantly worse than the control group. When presented with concrete cues, it turns out that CSA’s can remember more than when the cues are presented in abstract form. When presented with concrete cues, CSA’s performed about the same as controls. This shows that the information is available in memory, but that it is simply a problem with accessing the memory. One method which is an innovative future treatment is the sense camera. During this treatment, you get to see a photo every couple of seconds. This can be a cue to help people remember things which they don’t have access to, but that are stored in their memory. This method does work for people with amnesia.

Intrusive memories
However, for many people with for example PTSD, the memories they have do come back as flashbacks of earlier trauma. Intrusive memories/flashbacks are involuntary recollections of fragments of an earlier traumatic event, which mostly occur in visual form, accompanied by a strong sense of reliving. These flashbacks are frequently triggered by sensory cues from the environment that match stimuli presented during the trauma. These triggers are most of the time very innocent, like specific colours or sounds. Content (which serves as a warning signal) and related emotions like fear, guilt and anger, can lead to persistent psychopathology. Example: when someone has been in a car accident and has developed a trauma of that event, a trigger could be the sunlight that is shining on the window of a car. This cue immediately triggers the memory.
Intrusive memories can be from field perspective (where you see things from your own eyes) or from the observer perspective (where you see yourself in the memory). Earlier findings indicated that recurrent memories occur in PTSD, depression and OCD and social anxiety. People with OCD and social anxiety mostly have flashback experiences from the observer perspective, while people with PTSD and depression experience flashbacks from both perspective.

Selective implicit memory bias
Priming is the automatic transfer of earlier learning episodes on processing information in the current context. This process of priming might become dysfunctional in a particular context, for example in people with depression. Two studies have been done on priming, one focusses on conceptual priming (which is about the transfer of meaning) and one focusses on perceptual priming (which is about the transfer of sensations).
The first study was about implicit memory bias for threat in general anxiety disorder patients. In the research they compared 23 GAD patients with 23 healthy controls. They used an incidental learning task, in which people remember words or pictures without knowing it’s a memory task. For example: participants were told to imagine themselves at the beach. Then participants got a distraction task and after that they did a final task in which they had to finish word-stems for which the researchers said ‘complete this fragment with the first word that comes to your mind’. This way they could measure the implicit memory, by seeing if more beach-related words would come to mind. During the task, eight threat words, eight positive words and eight neutral words were randomly presented for ten seconds each. The results were that, when looking at the threat-related words, there was a great difference between GAD patients and controls. This is probably because to GAD patients, these threat words are very meaningful so they are more likely to complete word types with that kind of information. So patients with GAD show a selective implicit memory bias for threat stimuli and words were related to individuals current concerns.
The second study was about priming in the context of trauma, which might give insight in the role of priming in PTSD.

The idea behind perceptual priming is that if you are involved in a highly stressful situation, perceptual characteristics perform just below threshold activated in long-term memory and that automatically influences the detection of information related to your trauma. The hypotheses they were testing in this research were the following: ‘There is greater perceptual priming for neutral stimuli that are present in a ‘traumatic’ event than for neutral stimuli that are present in a neutral event. People high in trait dissociation show more perceptual priming than people low in trait dissociation. The degree of perceptual priming predicts intrusive re-experiencing one month later’. In this study they used healthy participants (people who scored high on trait dissociation and people who scored low on trait dissociation) and they used an encoding task of picture stories. Dissociation is a form of avoided encoding and is also considered a risk factor for the development of PTSD. Participants were presented with picture stories, both unpleasant and neutral ones. After that, they were presented with a blurred versions of picture identification (pictures of the stimuli in the stories and new stimuli). They wanted to see if high dissociators would know more often what the blurred pictures are in the trauma context. It turned out that the unpleasant story was more primed than the neutral story in high dissociators and that high dissociators score higher on both unpleasant and neutral picture stories, compared to low dissociators. Furthermore, for the unpleasant (trauma-related) story both groups scored higher than for the neutral story. So it is true that there is greater perceptual priming for neutral stimuli that are present in a ‘traumatic’ event than for neutral stimuli that are present in a neutral event. It is also true that People high in trait dissociation show more perceptual priming than people low in trait dissociation. Furthermore, the degree of perceptual priming predicts intrusive re-experiencing one month later. The strength of this research is that it focusses on encoding and retrieval in which the context is matched (both perceptual), that they used ecologically valid stimuli (pictures instead of words) and that there is more than one memory process captured in a single study: selective implicit memory (priming task), avoidant coping (dissociation/perceptual processing) and recurrent memory (intrusion questionnaire). The weakness of this design is that it is an analogue design.

Working memory
The working memory is a cognitive system involved in the active maintenance and manipulation (e.g., updating/inhibition) of mental contents in service of current goals. The past ten years, the working memory has become the most important memory process in psychopathology. This part of the memory system is about operations involved in the short term storage and processing of information and can be defined in terms of different components: the central executive, the visuospatial sketchpad and the phonological loop. A relevant research question is therefore which component is most likely to be involved in a certain disorder (e.g., visuospatial sketchpad in PTSD, phonological loop in worry/GAD).
There has been a study about working memory and intrusive memories. They wanted to answer the question whether a visuospatial interference task could help to impair memory consolidation after trauma. Participants were shown a movie for 21 minutes, followed by a 30 minute time-span of nothing. Next they were divided into three different groups. Group one had to do a tetris-game which interferes with the information in the visual sketchpad. Group two didn’t get any task and group three had to answer general questions. The results showed that for group one, the number of flashbacks was reduced after this task. So interfering with the visual spatial sketchpad of the working memory led to reduction of future re-experiencing. Of course in this research they didn’t use real-life trauma, but this research does give us interesting information. This study has also been replicated in Groningen, which showed the same results.

There are individual differences regarding working memory. The working memory capacity/mental flexibility is the ability to maintain access to goal-relevant representations and suppress irrelevant information. People who have a high working memory capacity can easily focus on a task and don’t get distracted, which people with a low working memory capacity can’t easily focus on a task without having interference of distracting stimuli. Because we know this is true, the following research question pops up: Do people high in working memory capacity have a reduced risk of persistent rumination after a stressful life event? Studies have shown that there is no evidence of intelligence improvement after working memory training.
 

Lecture 4

This lecture is about reasoning processes. According to the dual process model of anxiety there is a reflexive system and a rule-based system. When a phobic stimulus is presented, danger-related associations are automatically activated. This process is part of the reflexive system. These associations can trigger a fear response, that gives rise to avoidance. Furthermore, this fear response leads to all kinds of interpretations in the rule-based system of reasoning. So the stimulus is interpreted as threatening, which leads to the validation of threat and the behavioural decision the avoid the stimulus. This lecture is focused on the rule-based system.

Perception is not a passive bottom up process, but an active top down, constructive and inferential process. In a research on motivational sets, ambiguous pictures were chosen from magazines and children were asked to report what they were seeing. Group one was asked immediately before a regular meal and group two was asked immediately after a regular meal. It turned out that group one saw more food-related objects in the stimuli than group two, because for group one, food had something to do with their current concerns. Another research that has been done is called blinking and the beat. In this research, a teacher hung a string of Christmas lights blinking in random order in his class and then he turned on the music of the beatles. All of a sudden, it looked like the lights were blinking at the beat of the music, but of course this wasn’t the case. There was an illusory correlation between the blinking of the lights and the beat. So although there was no strong motivational set, we have a tendency to see causal relationships between two stimuli and to look for meaning.

Looking for meaning has a survival value by which it can predict future events and it can control the present. It also optimalizes the likelihood of obtaining desired outcomes and avoiding aversive ones. The downside of this mechanism is that illusory correlations are costs of otherwise functional cognitive adaptations. So usually these mechanisms are functional and helpful, but sometimes they aren’t. Functional cognitive adaptions can be qualitatively different (matter of kind: people with the disorder have another type of reasoning disorder than people who don’t have the disorder), quantitatively different (matter of degree: some people have a more severe form of reasoning bias than other people) or thematically different (matter of different content: people can have different current concerns and therefore have different reasoning biases). The book discusses the following reasoning processes: interpretative reasoning, attributional reasoning, expectancy reasoning, detection of covariation and hypothesis testing.

Interpretative bias
When measuring interpretative biases, researcher mostly use self-report measures. For example: people are asked what they hear when they hear a sound in the middle of the night. Some people would say a bugler, but other people would say it’s just a cat. The downside of these self-reports is that it requires introspection and that it is sensitive to self-presentation concerns, self-deception and demand. People also tend to vary across time in how they perceive ambiguous events Another way how the interpretative bias has been measured is by using homophones. In this type of research, ambiguous words like ‘DAI’ are presented and the participant has to write down the word he just heard. The options one could write down are ‘die’ or ‘dye’ and the word the participants chooses to write down says something about one’s interpretative bias. Of course, it is possible that people know what is being measured and they can interrupt the research.

In the lexical decision task participants are shown ambiguous primes (homographs), for example the word ‘growth’. After the prime, the participants are shown the word ‘disease’. Then they had to answer ‘yes’, because disease is a real word. When the word ‘easdise’ would have been shown, the participants had to say ‘no’, because this isn’t a real word. When growth is the primeword, some people are very quick when the word disease is shown, because they were expecting the word (for example, because they thought of the growth of cancer). When these people are shown the primeword ‘book’ and then the word ‘disease’, these people react much slower. For people who don’t make this association between growth and disease, it doesn’t matter for their reaction time if the primeword was growth or book. So the preference threat meaning is in line with current concerns. The lexical decision task has also been done with the primewords shown longer (500, 750 or 1200 ms). This way they could see what the effect would be if you give participants longer time to think. It turned out that for the 500ms-group, all people were faster at detecting threat and neutral words. However, for the 750ms and the 1200ms-groups, high trait anxious individuals only showed a facilitation to threat words. The explanation for this phenomenon is that high trait anxious individuals get stuck to a threatening interpretation during the later stages of processing.

Other research in this area has attempted to measure interpretation bias in real life. In this research, people are presented with a case, for example: ‘since your move to a new house, you have spent less time with your old neighbours. When one of them calls, you explain that it’s because of the move. Your old neighbour sounds…’ The participants then have to fill in the following incomplete word: ‘a..oyed’. Next, they have to say whether the neighbour will forgive them for keeping in touch and after every question they get feedback. Positive and negative words were used in this study. In turns out that the control group reacted faster to positive probes and slower to negative probes, while the anxious group reacted faster to the negative probe and slower to the positive probe. For the determination of causal influences, the CBM-I training has been introduced. This training is the same as the previous described research, but here the positive CBM group received 90% positive words and 10% positive words. It turned out that this training has an effect on a number of subclinical groups: high trait anxious individuals, high socially anxious individuals, people who have a high fear of spiders and high worries. It also had its effect on some clinical groups, particularly on GAD patients and people with a social anxiety disorder. Another type of intervention which is designed for the prevention of adolescent social and test anxiety, is the pasta-program. Here they use the interpretation task, that learns participants to see everything through pink glasses and that gets them to think more positive.

Causal attributions
Everyone makes causal attributions of events. These attributions can be internal or external (it’s my fault – it is due to others), stable or unstable (I just have no talent – I did not invest sufficient effort) and global or specific (I am a bad student – statistics are not really my strength). The depressogenic (pessimistic) attributional style (ATQ) involves internal, stable and global attributions when a negative incident happens and more external, instable and specific attributions when a positive incident happens. People with depression or anxiety react to a negative incident with more internal, stable and global attributions, while people with schizophrenia react to a negative event with external attributions (so they blame other people). This finding suggests that the different concerns of these disorders make different causal attributions. Another study that has been done used people who were in car accident. They picked out those people that could have a whiplash. What they measured was ‘how do you explain your current pain symptoms?’. Those people who associated their neck complaints with the whiplash, rated the severity of their symptoms much higher. So independent of the amount of pain someone is experiencing, when this pain is attributed to the whiplash ,the participant predicts a negative outcome. This is why doctors are discouraged to use the word whiplash.

Expectancy reasoning
The expectancy bias is a common (transdiagnostic) process, but it varies as a function of specific concerns. For example, in eatings disorders people think ‘if I eat something, I will get fat’ and in MDD people might think ‘If I go out, I won’t feel better’. People with psychotic disorder have a higher expectancy of negative events happening to themselves and people with an addiction might think ‘if I take this drug, I will feel much better’. Anxiety disorder patients tend to have a bias towards expecting aversive outcomes when phobic stimuli are presented. However, there are different types of outcome associations between the different types of stimuli. In dog phobia, people tend to afraid that the dog will do them harm and bite them, while people with social phobia are afraid of rejection. For people who are afraid of small animals it is now suggested that they experience disgust towards those stimuli or that they are afraid that they will be contaminated.

How can you study expectancy reasoning? This is possible by acting out the thought experiment procedure. Participants have to sit in a comfortable chair, in which they get the following instruction: ‘during the experiment you will receive shocks at certain moments. Also, a catheter will be inserted in your mouth, and taped to your cheek, so at certain moments a fluid can be rejected. This fluid will taste very bitter, and is quite nauseating. The fluid is, however, just like the shock, unpleasant yet harmless and without side effects. During the experiments you will be shown a series of slides of four types of animals: pit bull terriers, spiders, maggots and rabbits. Each slide will be shown for exactly six seconds and will immediately be followed by one of these three consequences: either you will receive the electrical shock, or a shot of the nauseating fluid will be injected to your mouth, or nothing will happen’. Before the treatment, phobic people thought that the spider pictures were more often followed by an electrical shock than the non-phobic people. The same was true for the fluid-group. After the treatment, the tendency to expect aversive outcomes declined significantly for the juice group and the shock group. However, residual UCS bias was predictive of relapse on self-report indices of spider BAT. So when you still feel some bias, you have a higher chance of relapse. An important remaining question is: how can it be that they do not correct their irrational UCS-expectancy in spite of the availability of disconfirming evidence?

Covariation bias
The covariation bias phenomenon is the perception of covariation, which says that when you have strong expectancies and the information is ambiguous then people typically see things in line with their expectancies. If the situation is straight forward and clear, then it might overrule with your expectancies. Usually you see that things that are high salient become illusory correlated. In a study spider phobics would think that the spider stimuli was more often followed by a shock, even though all the consequences were followed after the stimuli equally often. After the treatment this association declined. The people who were afraid of spiders connected these two events, because they were most salient. Those people who had a strong covaration bias were the ones who had a higher tendency to return their fear after two year. So covariation bias has a predictive validity.

Hypothesis testing
Hypothesis testing is a part of everyday reasoning. It is important to test our own beliefs and thoughts to make sense of the world. In everyday reasoning we rely on perceived utility (what I believe is true) and the perceived utility is strongly based on your current concerns. The ‘better safe than sorry’ algorithm is highly adaptive when a real threat is presented, but it is maladaptive when a phobic threat is presented because this immunizes against refutation. The Better safe than sorry-strategy consists of danger rules (if P then danger; verification rather falsification) and safety rules (if P then safe; falsification rather than verification). People who have an irrational fear have the tendency to the verification of danger rules and the falsification of safety rules, which leads to their anxiogenic beliefs to be maintained.

How do you test this particular hypothesis? You can do this by using the Wason Selection Task (WST), which identifies what type of information subjects select when asked to investigate tenability of ‘if P then Q rules’. During this task, four cards are presented with a letter on one side and a number on the other. The rule they are given is ‘if A on one side, then 4 one other side’. The participants have to indicate the card or cards that they definitely need to turn over to find out whether the rule is true or false for these cards. Using this task, you can see whether people use verification of falsification. In a non-clinical sample, most students chose the verification card because that one is the most obvious. Only a few students correctly chose the falsification card. This task has been done with neutral stimuli, but also with general threat-related words. People generally tend to verify danger-rules and they generally tend to falsify safety-rules. When you look at people with spider phobia, considering general threat words they falsify safety-rules and verify danger-rules, just like the control group. However, when people with spider phobia are shown spider-related words, they tend to verify danger-rules. So they select different types of information. People with hypochondriasis show the same pattern, including a bit more falsification of safety-related rules.

Emotional reasoning
In emotional reasoning people tend to use their emotions for information. Normally, when there is danger you experience fear. However, people with anxiety disorder have the tendency to think there is danger when they are experiencing fear, so they experience false alarms (fear without danger). So they infer threat on the basis of their fear response. Furthermore, when a stimuli is not recognized as false, then the conclusion is drawn that it is dangerous. Research has been done in which participants are told different scenarios (panic, social, spider, other, control) and the stories that were told differed in objective threat (yes/no) and fear response (yes/no). After the stories were told, people had to indicate whether they thought the situation was absolutely not dangerous or extremely dangerous on a continuum. The hypothesis was that non-fearful participants would have a high response to objectively dangerous stimuli. However, they thought that anxiety patients would have a high response to objectively dangerous stimuli and a high response when there was an anxiety response. The anxiety response was not restricted to their own disorder. People with social anxiety disorder also used an anxiety response for the OCD stories, which means there is a premorbid type of reasoning strategy. This might also explain the high comorbidity between different anxiety disorders, so why have a bigger chance of developing a certain type of anxiety disorder when you already have one other anxiety disorder.

Disgust-based emotional reasoning is thought to connected with OCD. People with OCD might have the following bias: ‘I might be contracted by illness when touching a seat’ -> touching toilet seat -> experience of disgust -> increased subjective risk of contamination. This means that the moment that people with OCD feel disgust for example for shaking hands, it confirms their thoughts that it is really dangerous to shake hands. In a study it turned out that when you have a high contamination fear, the feeling of disgust has a big impact. Right now this research is being done for sadness.

To look at the causal properties a study has been done where the people were learned to only look at the objective danger and not at the emotional information. Participants were presented with objective danger and objective save stories, which were followed by a fear or a no fear response. After that, participants had to indicate what would happen (one answer was correct and the other one was incorrect). By always correcting the participant for the objective information answer, they started to learn to ignore the emotional information. After this study, their emotional reasoning tendency dropped to zero, but people with spider phobia also rated the spider as less dangerous. So emotional reasoning might have an impact of the persistence of fear.

Lecture 5: thought processes

Repetitive Negative Thinking (RNT)
Repetitive negative thinking consists of rumination (big part of depression) and worry (big part of general anxiety disorder). Rumination is described as the repetitive and passive thinking about one’s symptoms of depression and the possible causes and consequences of these symptoms. In rumination people are more thinking about ‘why’-type of questions. These questions can concern broken relationships, arguments, criticisms, a broken car or oversleeping. Worry is described as a chain of thoughts and images, negatively affect-laden and relatively uncontrollable; it represents an attempt to engage in mental problem-solving on an issue whose outcome is uncertain but contains the possibility of one or more negative outcomes. In worry people are more thinking about ‘what if’-type of questions. These questions can concern things like old age, death, illness, unhappy kids, loss of job or deadlines. The key features of both these two concepts are recurrent thinking, the thinking is involuntary and people have difficulty to disengage from it.

You can make a discrimination between worry and obsessions. Obsessions can occupy your mind and is most frequent in obsessive compulsive disorder. Obsessions are more likely to be visual images, are involuntary and are accompanied by a sense of responsibility. Furthermore, obsessions are less realistic, easier to dismiss and are less distracting. However, the key difference is that obsessions are more egodystonic, so if feels like the thoughts are not compatible with their self, it feels like the images are not their own.

RNT has different terms and contents across disorders. In depression it’s called depressive rumination and the content is often current symptoms, negative experiences and failures. In GAD the term is worry and the people mostly worry about potential future danger. In PTST it’s called trauma-related rumination, in which people ruminate trauma and its consequences or implications. In social phobia the term is post-event processing, in which people are occupied with (recent) social situations. In OCD it’s called rumination and people ruminate about symptoms or implications. At last we have sleeping disorders, in which is it called pre-sleep cognitive activity and those people are mostly occupied by everyday problems or by the consequences of not sleeping. These aren’t all the disorders in which RTN is present, it also plays a role in panic disorder, eating disorder, hypochondriasis, pain disorder, substance use disorders, psychosis and bipolar disorder. This data suggests that RNT is definite transdiagnostic process.

During the lecture we had to do a test in which we had to think about deep questions, like ‘why are you the kind of person that you are?’. We had to write down how sad we were feeling before and after answering these questions to ourselves. Research has shown that when people are sad beforehand, then the sadness will even get worse. For happy people, these questions don’t really have an effect on most people. So these tests do work for people who are depressed or for people who have previously been depressed, in which you can see in what matter RNT is involved in symptom maintenance. Thomas Ehring designed a model of how RNT can affect the way you develop a disorder. The model describes that a triggering thought (which is influenced by your current concerns) can lead to repetitive thinking (so repetitive thinking is about your current concerns). This process brings about negative mood and more intrusions. Other processes that are effected by repetitive negative thinking is the development of negative thinking, negative memories and poor problem solving. This last thing is true especially for dysphoric people (people who are a little depressed).

Adaptive RNT
RNT isn’t always maladaptive, it is helpful for problem solving for example. Worry helps when it is appropriate (when it focusses on real objective concerns and when it is relatively brief). The stages of problem solving are definition/appraisal of the problem, generation of alternative solutions, selection of alternatives, implementing the chosen solution and evaluation of effectiveness. It is thought that phase of the definition/appraisal of the problem is dysfunctional in RNT. Another type of adaptive RNT is emotional processing. Emotional processing is described as the process whereby emotional disturbances are absorbed and decline to the extent that other experiences and behavior can proceed without disruption. It is known that repeated exposure to thoughts about upsetting events is beneficial, as it turns out in (imaginal) exposure in PTSD and expressive writing. Of course it’s not good to always think about disturbing things, but it is beneficial to think about such things every once in a while. Research on expressive writing has shown that depressed people who engage in expressive writing feel happier and less negative than before the writing exercises and anxiety tends to go down. People benefit most from expressive writing when their narratives contain more ‘causal’ words over writings and when they shift perspective over writings (from ‘I’ to ‘they’ and back). The conclusion here is that too much writing isn’t good because it creates the risk of getting into a sort of navel gazing or cycle of self-pity, but standing back every now and then and evaluating where you are in life is really important.

The Ruminative Response Scale (RRS) consists of 3 scales, the reflection scale (you try to understand why you are depressed, you think about why you feel this way), the brooding scale (what am I doing to deserve this? Why me?) and the depression-related scale (think about your feelings of fatigue and achiness). Brooding seems to correlated with depressive symptoms on the long run. In the beginning, when the scale was developed all the scale were about rumination. Later they developed the reflection scale, and it turned out that the reflection factor is protective against depressive symptoms. A study has been done where people had to fill in de Becks Depression Inventory and a couple of months later those same people had to fill in the BDI again. It turned out that the brooding items were correlated with depressive symptoms. Reflection was the suppressor variable, which was associated with less depression over time. So some types of rumination might be protective against depression in the long run.

So why does it go wrong? It seems that people in which it goes wrong think about insoluble problems (why me? What if my child dies?). They don’t think about good alternatives. Furthermore, their mode of thinking is different. In maladaptive RNT people think abstract, conceptual, evaluative and high-level construals (you make it personal). Adaptive processing is more concrete, process-oriented and non-evaluative construals. Examples of abstract questions are ‘what if I fail the exam?’ and ‘Why did this happen to me?’. Examples of more concrete questions are ‘What would I feel and think when failing the exam and what would I do next?’ and ‘What exactly happened?’. So if you are an abstract thinking and you make an exam, it would help to think ‘what if I fail the exam?’. To test how these modes of thinking are involved in symptoms Watkins & Baracaia tested year people who were either never depressed, remitted depressed or currently depressed. They had them engage in a problem-solving task and there we three conditions. The first group had to focus on their own state, the other group had to focus on process and the last group got no instruction at all. The problem-solving task involved stories in which people had to come up with problems. The state-oriented group had to ask themselves questions like ‘what am I doing wrong?’ and ‘what caused this problem?’ while solving the problem. The process-oriented group had to ask themselves questions like ‘How am I deciding what to do next?’ and ‘how do I know this is a good thing to do?’. The results show that people in the depressed condition didn’t really get better from the state-oriented instruction. What you also see is that the processed-focused instruction made them a bit better on the problem solving task. This was also the case for the remitted-depressed condition. There is some experimental evidence for the reduced concreteness hypothesis. People with depression have the tendency to think abstractly. This abstract modes of thinking maintains their negative mood and reduces problem solving ability. Abstract modes of thinking also causes overgeneralized autobiographical memory and stronger emotional reactivity. In PTSD the induction of abstract rumination after an analogue trauma leads to more (analogue) intrusions.

Thought suppression
People tend to not think about their worries. The white bear experiment is a good example of thought suppression. At first you get the instruction to not think about a white bear for one minute. After the minute is over, you get the instruction to think about anything, perhaps even a white bear. The white bear experiment shows the paradoxical effects of thought suppression. In the first phase of the experiment, there is an immediate enhancement in that there was in increase in ‘forbidden’ thoughts during suppression. During the expression period (second phase) there is an delayed enhancement or rebound, in that there is an increase in previously ‘forbidden’ thoughts during a free thinking period. In the expression period (if people have previously suppressed) they have a larger number of white bear thoughts than people who start with expression. So when people have to express after supress, then the rebound effect occurs in that people keep thinking about the white bear. While when people have to express before they supress, the thoughts about the white bear will decline, so they become better at not thinking about the bear.

Thought suppression as a transdiagnostic process? It is important to distinguish the attempts at suppression and its consequences. The attempts are present in all disorders, but the the paradoxical consequences (the rebound effect) aren’t evident in all disorders. You see it in PTSD, agoraphobia and insomnia but you don’t see it in specific phobia. There is insufficient evidence in GAD, somatoform disorder, eating disorders, substance abuse, mood disorders and psychotic disorders. These results make thought suppression a possible transdiagnostic process. This is interesting, because it is not evident in all kind of disorders, so what is an explanation for that? One of the factors that influence the magnitude of the paradoxical effect is the association between distractors and thought. What did you do when you didn’t want to think about the white bear? You probably wanted to distract yourself by thinking about a red rabbit. People try to replace the white bear thought with a thought of something else. These descriptives get associated with the forbidden thought. So when there is a problem with a broader theme (for example in social phobia) then there are much more situations or distractors that become tight to your mechanism and it pops up in all kinds of situations. However, associations within spider phobia may be much more restricted. So broader themes give rise to more associations. The other factor influencing the magnitude of paradoxical effect is the ironic process theory. These theory suggests that there two types of processes going on. There is an operating process that is intentional, effortful and conscious directing away from unwanted thought. There is also an monitoring process which is unconscious, automatic and scanning for failures. You can image that when you don’t have much cognitive resources, for example when you are depressed, then the operating process fails and the forbidden thoughts pop up more often. Thought suppression is also known to increase a negative mood and can lead to more intrusions.

Meta-cognitive beliefs
Meta-cognitive beliefs are thought to fuel repetitive thinking and thought suppression. Metacognition is any knowledge or process that is involved in the appraisal, monitoring or control of cognition. It can involve thinking processes and how they work and also the meaning of having certain thoughts (thought action fusion). For example, in the process of thought actions fusion, someone can think that thinking something is as bad as actually doing something. Metacognitive regulation are the processes that control and monitor cognition, for example attention, checking discrepancies and RNT en TS! Examples of positive metacognitions are ‘worrying helps me to prevent bad things from happening’ and ‘I need to worry in order to be organized. Examples of negative metacognitions are ‘worrying/ruminating will make me ill’ and ‘I have to control my thinking all the time’.

According to the metacognitive model, in the example of anxiety disorders, people see a trigger (what if I lose my job?) and positive meta-beliefs are activated (if I worry now, I will be prepared). But then they get carried away: ‘if I lose my job, I won’t have money, I won’t be able to pay the rent, etc.’ So then the negative meta-beliefs are activated. If that’s activated you get type two worry in which you think you are going crazy. You then try to come up with ways to regulate your worrying, so you become emotional but then you try to control your thoughts and you will be engaging in avoidance behavior to not think about it. This process itself will also fuel worry again. Metacognition includes RNT and TS and another strategy is metacognitive awareness and decentering. Decentering is about regarding your thoughts as mental events rather than reality. You just let your thoughts be thoughts and mindfulness training can help you with this. Another type of strategy of metacognitive regulation is to monitor your cognitive performance, for example you can evaluate your perception, your attention or your memory.

People with a checking OCD check all the time, and they wanted to see if there is something wrong with their memory. It turns out that there is nothing wrong with their memory, rather they are uncertain about their own behavior. The idea was that this uncertain about their actions may fuel checking behavior. They tested this in the following way: they had people with OCD engage in a gas-stove task. First they had a pre-test, in which they had to check the gas-stove and put it out and then they had to engage in 20 checking trials. It turned out that people who repeatedly checked the stove were less sure that their memory of putting of the gas-stove was right. So the more people checked, the less confident they were about their memory accuracy and they also reported their memories as less detailed and less vivid. It is important to note that the true memory was accurate. So the checking behavior itself is detrimental to your metacognition. This means that there is a vicious circle for the maintenance of checking behavior: checking causes distrust in the accuracy of memory, which would lead to more checking.

Metacognitive beliefs and regulation in the context of RNT are definite transdiagnostic processes and other regulatory processes are inclusive. In depression people have impaired metacognitive awareness. In OCD there seems to be an impaired trust in memory, but because this is not yet studied in other disorder we can’t say more about this. In schizophrenia people have an impaired reality monitoring. In OCD people don’t have this and the idea is that impaired reality monitoring is unique to schizophrenia.

Lecture 6

This lecture is about avoidance as a trans-diagnostic process in psychopathology. Cognitive therapy treats humans like a machine, but they need to recognize that they are working with human beings. They are working with human life, and those lives are best understood as stories. In these life stories everyone starts with what they are and everyone has goals about what she should be. Human beings are goal directed animals and even though we’re not always thinking about these goals, they are always there in the back of our heads. These goals are tied to how we perceive the world and influence how we act. Sometimes, the story can become interesting when something novel happens, something you didn’t expect. This novel thing can be positive (promise; hope) or negative (threat; anxiety). Something unexpected can cause chaos, which leads you to question all that you know and all your goals you previously wanted to achieve. In psychopathology, people tent to achieve certain goals and then something negative happens which creates a lot of chaos and distress.

In the lecture we’ve been told about a story about a dragon. One day, a little boy says to his mother that he saw a small dragon. His mother responded by saying that there is no such thing as a dragon. While the dragon was being ignored by the boy and his mother, the dragon grew bigger and bigger. Eventually, when the boy finally recognized the existence of the dragon, he became small again. This story was a typical example of what happens when you try to ignore a problem: the problem gets bigger. One reason why people could try to avoid novel stimuli is because of their pride.
Avoidance
There are several types of avoidance. First you have overt/escape avoidance, which is when an individual does not enter, or prematurely leaves, a fear-evoking situation. Second you have safety behaviour (within-situation safety-seeking behaviour), which is the overt or covert avoidance of feared outcomes. Examples of this type of behaviour is sucking mints to ‘prevent’ vomiting or distracting oneself when in the presence of fear cues (self-deception, psychoanalytic defences).

Avoidance does make sense, because it has offered a great deal of success in controlling the material world. We are taught to control our emotions and thoughts (for example we are told ‘don’t be a baby’). Furthermore, avoidance is more immediately reinforcing. However, the problem with avoidance is that it doesn’t work, because the human mind is constructed differently that the outside world and we cannot remove our history (for example: when someone says ‘mary had a little ….’, we all know what word has to be filled in, this is an automatic process which is hard to supress). Avoidance also maintains or increase negative effect because this way you can’t learn that danger cues are actually safe and there can be rebound effects (supressing your anxiety may help for now, but in the long run in can come back twice as bad). Last but nog least, avoidance narrows your life because you’re avoiding situations that are necessary to have a social life. So avoidance can take a lot of space in one’s life.

Avoidance basic research
In the basic research on avoidance they tried to train people to avoid or approach novel animals (animals with which people didn’t have any experience). Participants got a joystick that they had to pull towards them when they had to approach an animal and that they had to push away from them when they had to avoid an animal. The results showed that the animal participants had to avoid was being liked less than the animal that was being approached and the other way around. The fear that was being measured showed that the girls were more afraid for the avoided animals than boys. These results seem logical, because when you approach something, you actually say to yourself that you are strong enough to do this and that you can handle it.

Avoidance as a transdiagnostic process
Avoidance is part of the DSM criteria, especially in the different type of anxiety disorders. Not only contributes avoidance to the development of disorders, it also prevents benefits of treatment. First we will discuss a study about avoidance in social anxiety. In social anxiety, the safety behaviours that are used contribute to the likelihood of the fear outcome occurring. What they did was they selected a socially anxious group and a non-anxious group. Both groups were told that they had to interact with another person one on one and that other person was a confederate. There were two conditions, the negative appraisal condition and the positive appraisal condition. In the negative appraisal condition the researchers created a socially anxious framework for the interaction, for example by telling them that it may take some effort for the two to understand and relate to each other. In the positive appraisal condition the researchers just said it’s pretty likely that the other person would like them. The results showed that in the negative framework condition, socially anxious people spoke less than the non-anxious people and they showed less intimacy. There was no difference between the two groups in the positive framework condition. This means that de socially anxious group does have the social skills, but that they don’t use them because they want to protect themselves. The confederate was also asked which person they liked and in the negative framework condition he liked the non-anxious people better than the socially anxious people, while in the positive framework condition there wasn’t any difference. So the point here is that don’t opening up to others leads to a negative evaluation by others, while that is exactly what the socially anxious people are afraid of and want to avoid.

In a study about avoidance in depression, they did the Beck depression inventory and they measured the amount of avoidance. Then they assessed an amount of reward probability and they gave people these diaries in which they had to record what they were doing and they had to rate how positive these activities were. It turned out that the relation between the avoidance and depression was mediated by decreased availability of reward. So again the behaviour of the individual contributes to the suffering one is experiencing. When looking at avoidance and PTST, avoidance is a contributing factor to the severity of PTSD. In one prospective study, they assessed mental defeat and avoidance/safety behaviours. What they found was that both variables represented avoidance and predicted PTSD symptoms over nine months. This relationship remains significant when covarying for gender and perceived severity of assault.

Avoidance prevents treatment benefit
On the base-line, we human beings are more likely to approach than avoid. We want to explore and this way we can naturally learn that things we thought were dangerous, aren’t dangerous at all. They did a study with participants that were agoraphobic and these participants had to have at least five situations which they were avoiding. They made two groups, group one got regular exposure without getting any instruction on safety seeking behaviour and group two was explicitly told not to use any safety seeking behaviour. They were tested before and after the exposure and it turned out that for the non-safety behaviour group the anxiety changed, while for the other group it didn’t. The non-safety behaviour group also had a less belief rating of how likely they thought the catastrophe would occur.
Another study has been done with claustrophobics. Participants had to enter a small dark room and one group they gave exposure with distraction task. Because research on this topic is ambivalent, this study developed a cognitive load distraction task to make sure that the participants had to pay attention the task. The results showed that when people were distracted, the perceived anxiety wsa higher than when they paid particular attention to the threat. They would benefit most when they paid attention whether or not the feared outcome was occurring. This means that being in the event isn’t enough, you really have to pay attention. Distraction prevented the benefits of exposure. The return of fear in follow-up was the lowest for the group of people who paid attention. So, both of these studies indicate that avoidance (distraction/safety behaviour) prevents new learning taking place.

Basis research of approach and approach as a transdiagnostic process
Blanchard did a study in which a created environments (fields) where he could study rats. He started making stories for these rats and it turned out that when a cat would try to catch the rat, the rat would go back to his house. What does he do next? The rat freaks out for about a day and then it peaks his nose out of his house. He would do a few short runs, so eventually he would explore the whole territory again. The world is then opening up in a way that is satisfying form him. So, the rat actively went out and explore even though this increased his fear.
When looking at approach as a transdiagnostic process, you see that exposure therapy works for different types of anxiety disorders (PD/A, SAD, OCD, GAD and PTSD). Furthermore, behavioural activation therapy seems to be beneficial for depression. In this type of therapy the client and the therapist make a plan for the client to actively start doing things. New research has been done with exposure in addiction, a field that seems very promising. Exposure is not something that only happens in cognitive behavioural therapies, but also has its grounds in for example psychodynamic therapies and humanistic therapies.
What changes when facing what is feared? Older models suggested that changing eliminated the fear structure, but more recent research explains that this isn’t true. We cannot get rid of the older associations that we have formed. The newer perspective is that the old associations remain, but that there is something added. An element of adding is fear tolerance. In one study about this, they had participants come in and they told them to put a mask on their face (this was to elicit a panic attack). The first time they all did it immediately, but the first time it was up to them to decide how long they would wait before putting the mask on. This means that they had control of what was happening. One group got acceptance instructions (just feel what you feel, just notice), one group got relaxation instructions and one group got no instructions at all. The results showed that in trail two and three, the people who received the acceptance instructions didn’t avoid putting the mask on immediately, but the relaxation group avoided a lot. This means there is more avoidance in the two other groups than in the acceptance group. There we no differences on distress or unpleasantness during CO2 changes, so they had the same amount of fear. However, despite this same amount of fear, the acceptance group would wait less longer.

Another aspect is self-efficacy. In a study they again invited agoraphobics who avoided five different situations. They did an exposure and they found that exposure helps, so they were more likely to do the tasks in their situation. However, there was also generalization, so people that weren’t being treated were also more likely do to the task. These benefits were predicted by self-efficacy, even when controlling for anticipated and actual anxiety. But reduced anxiety did not predict benefits when controlling for self-efficacy. When you avoid something you tell yourself that you can’t do it, but when you approach something you tell yourself that you can.
A new field that has been developed is called posttraumatic growth. It says that when something really bad has happened to you, your world is a complete chaos. However, by engaging it in a fundamental way (so towards it) you can be stronger at the end than you were at the beginning. Working through it can benefit your personality and your life.

Lecture 7

This lecture was about transdiagnostic theories and how you use this in clinical practice (especially in eating disorders). In psychopathology were learned much about looking at different disorders. So we learned a lot about anxiety disorders, for example to distinguish between social anxiety disorder and general anxiety disorder. We have developed interventions based on all those different disorders. However, most theories don’t look at comorbidity. Transdiagnostic processes look at similarity between disorders instead of looking at the differences.

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p>Eating disorders
In the DSM they put feeding and eating disorder together, which consists of a category with pica and rumination disorder, avoidant-restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge-eating disorder, other specified feeding and eating disorders and unspecified feeding and eating disorder. People with anorexia nervosa have an over-evaluation of their shape and weight and their control. They participate in active behaviour to maintain an unduly low body weight, which must be less than 85% or a BMI<17,5. A lot of people who have anorexia nervosa actually die from having this disorder. People with boulimia nervosa also have an over-evaluation of their shape and weight and their control. However, unlike anorexia patients, patients with boulimia engage in recurrent binge eating. Binge eating is referred to as eating an objectively large amount of food which is accompanied by a sense of loss of control. They also show extreme weight-control behaviour. This disorder can be dangerous because throwing up too much can actually kill you. A lot of people with eating disorders fall into the category of other specified feeding and eating disorder. This group has no diagnostic criteria and is a residual category for eating disorders of clinical severity. These people can have severe problems, but they don’t fulfil the full criteria of the DSM for boulimia nervosa or anorexia nervosa. Important to note is that obesity is not a psychiatric diagnosis. There people do have the aspect of binge eating disorder, but they don’t throw up. Because they don’t throw up they often gain weight, which leads to them getting overweight. There is a group that has a high comorbidity with psychiatric problems or social problems, but there is also a group that is just obese.

Most striking
The video that was shown during the lecture shows that more or less the same psychopathology is seen across the different eating disorder diagnoses and the severity is much the same too. People can also migrate from their diagnose to another, so people can suffer from anorexia and then switch to binge eating disorder or the other way around. This left us with the question that these disorders have in common. When you look at the similarities, all eating disorders involve an over-evaluation of bodyshape and weight and their control, which is peculiar to eating disorders and is uncommon in the general population. The core psychopathology in eating disorders is involved with clinical perfectionism, low tolerance of emotions, interpersonal problems and negative self-evaluation. The core psychopathology leads to disturbed behaviour (they eat less or have binges or compensate by exercising), that again starts psychopathology. This model is also described in the article and says that there is actually a vicious circle.

Processes
Attention in people with eating disorders is directed to their body. They tend to focus on negative aspects of their own body, while focussing on positive aspects of the bodies of other people. Normal people actually act the other way around. People with eating disorders show the same pattern concerning food, but here there is a difference between anorexia and boulimia in that people with anorexia are able to distract their attention away from the food while people with boulimia have difficulty doing this. Thinking processes in people with eating disorders are concerned with being overweight and are about bodyshape, weight and food. They have thoughts like ‘people will love me if I am 30 kilo’s’. They also have a negative self-esteem. Normal people describe themselves in different roles (sister, mother, etc.) but people with eating disorders evaluate themselves for the biggest part only in terms of weight and shape.

Avoidance in people with eating disorders concerns eating fat food and sometimes they even avoid looking at food or drinks. They also avoid situations where they cannot control food, like restaurants or birthdays. Furthermore, they are either weighing their selves excessively or they avoid them. They also tend to avoid mirrors. Safety behaviours in people with eating disorders involve strict rules (I can eat jelly but I can’t eat peanut butter) and they repeatedly check their body. An example for this last thing is that they can’t stop checking if they have a fat role over their jeans. Reasoning in people with eating disorders involve estimating that negative outcomes will occur as a consequence of their weight and shape in boulimia nervosa and that eating helps to reduce negative moods and boredom (also in boulimia nervosa).

Transdiagnostic theory
Boulimia nervosa can be treated with CBT, where it focusses on clinical perfectionism, core low self-esteem, mood intolerance and interpersonal difficulties. Important to know is that distinctive clinical features are maintained by similar processes. The core psychopathology is overweight of concerns of body shape and weight. So how do they treat people with eating disorders? They can give them cognitive behavioural therapy of which they get twenty sessions. They always ask the opinions of an important caregiver of partners and always ask brothers and sisters. They also look for comorbidity (like depression) and check the medical situation (because they also may be a medical reason for why people have disturbances in their weight). Furthermore, they ask about the individual maintaining processes (in questionnaire or interview) and ask about their concerns and their safety behaviour. Sometimes patients have been doing this type of behaviour for so long that they don’t even know that they are doing it. That’s why you need the opinion of people around them (brothers/sisters). An important aspect of the therapy is that you motivate them from the beginning! You discuss why the person wants help, what he/she wants to change, what the barriers to that change are and the consequences of their disorder. Motivation is very important, because not eating gives those people a certain kind of kick, they tell themselves that they are strong for resisting food. This means that when they start therapy, you’re not giving something to them, but it feels like you’re taking something away from them.

When you start CBT, in all your sessions you start with agenda setting and you use socratic motivation (so you are questioning their thought) and you give them the structure for 20 or 40 sessions. Patients really have to realize there is a lot of work to do. In phase one it’s about quick changes and people who do well in this first phase also have a good prognosis. You almost always start with diet management, which means structuring the eating patterns. This means eating at regular times (six times a day), following with start talking about the amount of food and then you start talking about the sort of food they have to eat (you don’t want them to only eat carrots). In phase 2 you have a short break and you talk about the motivation op the patient and about the barriers for change. Why do we do this? Because when you take away their control, these people won’t be feeling happier, it feels like you’re taking something away from them. Phase 2 consists of one or two sessions and it is best to do these sessions while patients are surrounded by people who are important to them. Phase 3 involves tackling cognitions, doing behavioural experiments and you give them exposure (on body checking, situations and food). People with an eating disorder also tend to do exercises when they just sit on the chair: they are moving their feet while sitting because they think it will burn calories. They also sit on the chair like this because otherwise they think their legs seem fat. This means that phase 3 also involves teaching them to exercise normal and to just sit on a chair like normal people do. When people with an eating disorder stand in front of a mirror they immediately look at the ugly parts of themselves, so if you use mirrors in your therapy you have to give them positive exposure (to look at the whole body and learn them to have a good feeling about it). Important to know is that you never put someone with an eating disorder just like that for the mirror, because it will increase the psychopathology. In your interventions you always have to be aware of the specific diagnoses, for example: for binge-eating you can use cue exposure, but this intervention doesn’t work for people with anorexia, because you would be glad if people with anorexia would eat at all. So there are differences in intervention strategies, but the core mechanism between the disorders is the same. In phase 4 the patient becomes the therapist and you talk about the prevention of relapses, because eating disorders are (just like depression) known for their high relapse rates.

There is a treatment protocol, but the other thing therapists are working with is resilience (this is not about the disorders and treating it, but it’s about wellbeing and how you can cope with problems and make something of your life). Resilience is a part of positive psychology and it has shown to be effective when working with young people. The transdiagnostic process has also influenced many organisations. It is important to know that eating disorders have very much in common. If we treat those people in different institutions it’s very difficult for them to get in the right place. 68% of the young people with bulimia we’ll never see, so don’t make too much difference between them.