Heinz Kohut, founder of the school of Self-Psychology, tended to see human beings in kinder and more benevolent terms. He hypothesized that the real cause of anxiety was a lack of empathy (“mirroring” was the term he used) on the part of the parents (known as self-objects in this theory). From these “empathic failures,” the child would experience a primary anxiety, which he called “disintegration anxiety,” instead of the more healthy responses of liveliness, joy and pride. According to Kohut’s theory, the way to correct this is to provide the patient with more mature self-objects in the form of a therapist, who would provide the structure and “soothing” the child had missed in his childhood. Through this process, the patient would eventually understand his past and forgive the errors of his parents, realizing that we are all heirs to an imperfect history.

Kohut made an important contribution to our view of child development, but unfortunately for his followers, his contributions occurred just as psychoanalysis was beginning to lose its predominance in psychiatry in favor of biological psychology and cognitive therapy. His kinder and gentler ways have been replaced by medications and rational analysis.

COGNITIVE THEORIES OF ANXIETY

Cognitive therapy, as developed by Dr. Aaron Beck, was originally intended to treat depression. With time, however, the model was extended to include many other pathologies including anxiety. Two major reasons, I believe, account for the success of cognitive therapy. First, it was a more practical approach than psychoanalysis, dealing in its approach with observable realities. Instead of treating abstract entities like “castration anxiety” and “Oedipal complexes,” it dealt with observable behaviors—panic attacks, obsessions and depressive states. This led to, among other things, better research studies, since the results and the processes were easier to measure. The second factor in its success was that the cognitive therapists were diligent, systematic and skilled researchers, not the case with psychoanalysts, who often treated their “science” more like a religion in which you either believed or didn’t.

Many of the recent studies—in which cognitive methods are compared with other short-term therapies, such as interpersonal therapy or even short-term analytic therapy, in a head-to-head manner—do not convincingly demonstrate the superiority of cognitive therapy except, perhaps, in compulsions and specific phobias where it is easy to design a behavioral protocol.

Most clinical psychiatrists I have spoken to do not feel that cognitive therapy lives up to its promise of superiority as heralded in research studies. Nevertheless, it is a useful tool in our therapeutic armamentarium. Perhaps its greatest contribution has been to force the field of psychotherapy back into the realm of reality and require all schools to test out their theories in well-designed research protocols rather than relying simply on their theories and beliefs.

According to cognitive theory, the core feature of generalized anxiety—worry—is seen as maladaptive information processing that leads to the perception of threat. This is in contradistinction to cognitive theories of depression where the cognitive distortion is about loss and inadequacy. Cognitive models of anxiety may be subdivided into models of generalized anxiety disorder and panic attacks.

GENERALIZED ANXIETY DISORDER

The beliefs or dysfunctional assumptions involved in generalized anxiety may be highly varied, but tend to revolve around the following themes:

1) Interpersonal confrontation and conflict
“I get upset every time she calls.”
“How am I going to tell him this?”
“He makes me furious every time I speak to him.”

2) Competency and Capacity (actually the lack of these two)
“If I make any mistake, I have failed.”
“If something is imperfect, the entire product is no good at all.”
“I cannot cope with this. I am not up to it.”

3) Acceptance (the lack thereof)
“I am nothing if I am not loved.”
“I always have to please others.”
“If someone criticizes me, I am worthless.”

4) Excessive Responsibility for Others
“I am responsible for people’s enjoyment when they visit with me.”
“I am totally responsible for the way my children turn out.”
“I worry about my children having a bad day in school.”

5) Social Catastrophe (may be in GAD or Panic Attacks)
“I am going to make a fool of myself.”
“What if I sound stupid making that presentation?”
“If I faint at the restaurant, I will be totally humiliated.”

6) Worrying about Minor Matters and Ruminating
The person here worries about things that don’t bother other people, such as being late for an appointment, catching a virus (the avian flu is a popular one these days), or getting lost.