Identifying which variables may be underlying patients’ problems is a crucial part of developing effective treatment plans. While traditional diagnosis-specific approaches prescribing different interventions for separate disorders may target specific mechanisms to reduce symptoms, many tend to overlook the fact that multiple mechanisms often are driving and maintaining clients’ ongoing suffering.
Fortunately, there has been increasing interest in and support for an approach that focuses specifically on targeting the transdiagnostic mechanisms—underlying vulnerabilities and patterns of response that are believed to trigger and maintain cognitive, behavioral, emotional and physiological symptoms across diagnostic categories—that lay at the heart of patients’ problems.
Today, we’ll take a look at some of the common vulnerability mechanisms that underlie anxiety disorders. Identifying these variables is the first step in tailoring treatment; you’ll then have the opportunity to select from a range of empirically-supported interventions that specifically target the root causes of the presenting problems.
Pervasive Beliefs, or Schemas
Schemas are pervasive, deeply entrenched beliefs with the potential to influence thinking patterns, behaviors, mood and interpretations of events. Schema content can include core negative beliefs about oneself (e.g., “I’m a loser”), others (e.g. “People are uncaring and judgmental”), the world (e.g., “The world is a dangerous place”), and the future (e.g. “Nothing’s ever going to work out for me”) .
Negative schemas have been linked with anxiety disorders and many other problems (A.T. Beck et al., 1985), and can act as a lens that distorts reality to conform with patients’ automatic thoughts affiliated with negative experiences. You can often identify schemas through patients’ automatic thoughts affiliated with negative emotional experiences (A.T. Beck et al., 1979; J.S. Beck, 2011).
Anxiety sensitivity (AS) is the fear of anxiety-related sensations due to negative expectations about experiencing anxiety—sometimes called the fear of fear itself (Reiss & McNally, 1985). It involves somatic, cognitive and social consequences of anxiety, with some dimensions more specific to certain disorders (e.g., somatic fears in panic disorder, and fears of publicly observable anxiety reactions in social phobia).
Anxiety sensitivity is associated with numerous problems, including agoraphobia, generalized anxiety disorder (GAD), panic, and PTSD (Naragon-Gainey, 2010).
Correlations between AS and thought suppression (a response mechanism) have been shown to additively predict anxiety symptoms (Keough, Timpano, et al., 2010) and raise the risk for substance use disorders (Schmidt, Buckner, et al., 2007).
David Barlow (2000, 2002) found that a diminished sense of control over aversive events and emotional experiences was a psychological vulnerability mechanism for emotional disorders, including chronic anxiety and depression.
Early experiences of diminished control increase the likelihood of interpreting future events as being also out of one’s control (Chorpita & Barlow, 1998), and is thus implicated as a vulnerability factor for anxiety. Changes in perceived control may explain improved cognitive-behavior therapy outcomes for anxiety disorders.
Intolerance of Uncertainty
There is considerable evidence that points to intolerance of uncertainty (IU) as a transdiagnostic vulnerability and maintaining factor across anxiety disorders, including social anxiety, panic, agorophobia, GAD, and OCD, as well as depression (Carleton et al., 2012; Mahoney & McEvoy, 2012).
IU has been linked with the response mechanism of worry (Meeten et al., 2012), and also combines with perfectionism in OCD. A cognitive behavioral protocol (CBT-IU) specifically targeting intolerance uncertainty and its related constructs (worry, metacognitive beliefs about worry, negative problem orientation, and cognitive avoidance) has been shown to be efficacious in treating GAD (Robichaud, 2013).
Because of its link with multiple disorders of negative affect, IU may be a key mechanism explaining the high incidence of co morbidity among these types of problems (Gentes & Ruscio, 2011).
Perfectionism is a transdiagnostic risk and maintaining factor for anxiety and depressive disorders, and is associated with poorer treatment outcomes for those conditions (Egan et al., 2011).
When targeted directly in treatment, clinical perfectionism been associated with reduced anxiety, depression and eating disorders, which underscore its relevance and influence across diagnoses as a transdiagnostic mechanism (Egan et al., 2012; Riley et al., 2007; Steele et al., 2013).
Negative Problem Orientation
The National Institutes of Health defines negative problem orientation (NPO) as a dysfunctional set of attitudes related to problem solving ability. NPO is widely recognized as a cognitive vulnerability underlying GAD (Koerner & Dugas, 2006) and correlates with both GAD and OCD symptoms (Fergus & Wu, 2010).
In 2011, Fergus and Wu identified NPO as the single cognitive variable that correlates with mood and anxiety symptoms, including depression, social anxiety disorder, GAD, and OCD, which suggests that it may confer a general vulnerability to mood and anxiety symptoms.
Fear of Evaluation
Evaluative concerns often accompany presenting problems such as transdiagnostic worry, shame and embarrassment related to psychological symptoms. Fears of both positive and negative evaluation are key features of social anxiety and also link with clinical perfectionism (Yap et al., 2016).
Inflated Responsibility and Threat Estimation
These mechanisms combine as a core factor in OCD (OCCWG, 2005), and are implicated in anxiety in general (Tolin et al., 2006). Considering mechanisms of threat bias and responsibility for harm is relevant to case formulation approaches to treating anxiety, depression, and worry (Persons et al., 2013).
Popular psychology has paid increasing attention to the importance of building distress tolerance over recent years. The focus is appropriate, as distress tolerance—or, more accurately, intolerance—is implicated as both a vulnerability and maintaining factor underlying anxiety and many other disorders (Keough, Riccardi, et al., 2010; Clen et al., 2011; Richards et al., 2011).
The way people perceive their capacity to tolerate distress influences how they respond to those emotions and contexts (Leyro et al., 2010).
Thus, the perception I can’t handle this, where “this” is one more minute of anxiety about a social situation or worry about whether one locked the door before leaving the house, often elicits response mechanisms and behaviors that perpetuate patterns of psychological problems.
Such response mechanisms may include things like social isolation (behavioral withdrawal), thought suppression (cognitive avoidance), or self-harm (emotion-driven behaviors).
These are just some of the mechanisms that can lie beneath the clusters of symptoms for which clients may seek help. Additional mechanisms to look for in patients presenting with anxiety disorder symptoms include neurological predispositions (e.g., impaired arousal or inhibitory control, executive functioning deficits), and metacognitive beliefs (e.g., “Worrying will help me avoid embarrassment and harm”).
Once you’re able to identify the vulnerability mechanisms that are at the root of your clients’ suffering, you’ll be better equipped to determine the most appropriate avenues for treatment.
As clinical research in the treatment of transdiagnostic mechanisms increases, there’s simply no need to rely only on protocols aimed at broad diagnostic categories, which may or may not get to the heart of the issue at hand.
Rochelle Frank, Ph.D., is a clinical psychologist in Oakland, CA and coauthor of The Transdiagnostic Road Map to Case Formulation and Treatment Plannng: Practical Guidance for Clinical Decision Making
She is an assistant clinical professor in the clinical science program at the University of California, Berkeley, and has more than 25 years of clinical experience in outpatient inpatient, and residential settings. She specializes in the treatment of severe mood disorders, borderline personality disorder, and trauma and dissociative disorders.