Anxiety disorders are extremely widespread in the United States, with a lifetime prevalence of up to 33.7% (Bandelow & Michaelis, 2015). In addition to taking a large emotional toll on affected individuals, anxiety disorders also take a large economic toll on the country, with one study estimating the total cost per year to be $42.3 billion (Greenberg, et al., 1999). There are many different types of anxiety disorders recognized by the DSM V(Kessler, et al., 2005). Some of these include panic disorder, generalized anxiety disorder, post-traumatic stress disorder, and specific phobias (Kessler, et al., 2005). These anxiety disorders are all complex and unique but are all unified in that they share at least one main symptom; anxiety (Leichsenring & Salzer, 2014). Feelings of anxiety are not, however, limited to the clinical population, with between 80% and 99% of the non-clinical population experiencing thoughts considered to be unwanted, unintended, recurrent, and difficult to control (Larsson, Hooper, Osborne, Bennett & Mchugh, 2015). This is important because it is believed that if these negative thoughts become severe enough, they can develop into anxiety disorders (Clark & Rhyno, 2005). Symptoms of anxiety can include physical symptoms such as sweating, shaking, and muscle tension, or can be thought based symptoms, such as excessive worrying (Craske, et al., 2009). One aspect of anxiety that researchers are particularly concerned with is avoidance, as it has been shown to be a factor in the persistence of anxiety disorders (Rudaz, Margraf, Becker & Craske, 2017). Anxiety that causes an individual to avoid doing the things that they want or need to do can quickly develop into an anxiety disorder (Beckers & Craske, 2017).
Current treatments for anxiety that have been proven to be effective involve psychological therapies and medication, whether alone or coupled together (Bystritsky, Khalsa, Cameron & Schiffman, 2013). Cognitive Behavioral Therapy (CBT) has become the gold standard for treatment of anxiety and is currently the most supported by research (Arch, Wolitzky-Taylor, Eifert, & Craske, 2012). One of the integral parts of CBT is cognitive restructuring, which aims to identify negative thoughts that an individual has and reframe them so that they are less anxiety inducing (Larsson, Hooper, Osborne, Bennett, & Mchugh, 2015). The other integral part of CBT is exposure, where individuals are exposed to the situations causing them anxiety (Arch, Wolitzky-Taylor, Eifert, & Craske, 2012). The main purpose of CBT is to have a reduction in symptoms, which will therefore decrease avoidance (Kleim, et al., 2013). In a clinical trial by Hoffman and Smits done in 2008, CBT was proven to be an effective treatment compared to a placebo group. CBT has been proven to be effective in reducing symptoms of anxiety associated with post-traumatic stress disorder, obsessive-compulsive disorder, panic disorder, generalized anxiety disorder, social anxiety disorder, and specific phobias (Kaczkurkin & Foa, 2015). While CBT has been proven to be effective, there have been studies that have shown issues with adherence to treatment, such as drop-out rates and premature discontinuation (Swift & Greenberg, 2014).
Another treatment for anxiety that emerged more recently is Acceptance and Commitment Therapy (ACT) (Masuda, et al., 2010). ACT aims to reduce avoidance by increasing psychological flexibility, increasing acceptance of uncomfortable emotions and focusing on strengthening an individual’s values (Arch, Wolitzky-Taylor, Eifert, & Craske, 2012). ACT primarily uses a technique called cognitive defusion which encourages individuals to separate themselves from their negative thoughts and recognize that their thoughts do not inherently have any meaning (Yovel, Mor, & Shakarov, 2014). ACT has less support than CBT, however it has been shown to be effective in numerous studies. (A-Tjak, et al., 2014). It has been shown to be effective in treatment of obsessive-compulsive disorder, panic disorder, social anxiety disorder, and post-traumatic stress disorder (Arch, Wolitzky-Taylor, Eifert, & Craske, 2012). In addition, individuals treated with ACT have a much lower dropout rate, and a much higher adherence rate to difficult activities such as willingness to experience negative thoughts than those using CBT (Twohig, et al., 2018).
Despite the studies backing the efficacy of both ACT and CBT for anxiety disorders, little is known about why these treatments are effective, and what makes each treatment more or less effective than the other (Arch, Wolitzky-Taylor, Eifert, & Craske, 2012). Recently, there have been more studies done to compare the effectiveness of cognitive restructuring and cognitive defusion (Deacon, Fawzy, Lickel, & Wolitzky-Taylor, 2011).
In a recent study, the effects of cognitive restructuring and cognitive defusion over a time period of approximately an hour were compared, and it was found that both treatments were found to significantly reduce negative feelings but were not significantly different from each other in their efficacy (Yovel, Mor, & Shakarov, 2014). There was, however, a difference in that the cognitive defusion group had an increase in acceptance, while the cognitive restructuring group did not (Yovel, Mor, & Shakarov, 2014). Another result of this study was that the individuals who were assigned to the cognitive defusion group did not feel that their treatment was effective, despite results showing that it was, which reinforces the core principle of ACT which is that the goal is not to reduce anxiety, but to practice acceptance in negative situations (Yovel, Mor, & Shakarov, 2014).
In another study, the effects of cognitive restructuring and cognitive defusion were compared to the believability of a negative thought, discomfort felt over a negative thought, negativity associated with a thought, and willingness to experience the negative thought, which took place over a time period of 5 days (Larsson, Hooper, Osborne, Bennett & Mchugh, 2015). The results from this study showed that the group that practiced cognitive defusion had a greater reduction in believability of a negative thought and discomfort of the negative thought, and had a greater increase in willingness to experience the thought than the participants in the cognitive restructuring group. Both the cognitive defusion and cognitive restructuring groups showed a decrease in negativity of the thought, but there was no significant difference between the two groups (Larsson, Hooper, Osborne, Bennett & Mchugh, 2015). In addition, the cognitive defusion group began to rate their negative thoughts as unbelievable, comfortable, and willing, as opposed to their initial ratings of believable, uncomfortable, and unwilling (Larsson, Hooper, Osborne, Bennett & Mchugh, 2015). While the cognitive restructuring groups did experience a reduction in believability and discomfort and an increase in acceptance, unlike the cognitive defusion group, they were no more likely to rate their thoughts as comfortable or willing (Larsson, Hooper, Osborne, Bennett & Mchugh, 2015). Both groups maintained that the target thought was negative despite the decrease in feelings of negativity (Larsson, Hooper, Osborne, Bennett & Mchugh, 2015).
These results of the previous studies are important to our current study as they explore aspects of anxious thoughts that are more closely related to the principles behind ACT, suggesting that the efficacy ACT may be just as good, if not greater, than the efficacy of CBT. To date, there have been no studies showing the effects of ACT and CBT treatments done over a one-month period of time in college students. The purpose of our study, therefore, is to evaluate whether the main component of ACT, cognitive defusion, or one of the two integral parts of CBT, cognitive restructuring, or both, will have a significant impact on an individual’s anxiety, worry, and psychological flexibility, and if so, which method is most effective for each variable. I predict that subjects in both the cognitive restructuring and the cognitive defusion groups will experience a reduction in worry and general anxiety, and an increase in psychological flexibility. I expect that due to the different paradigms and core components of CBT and ACT, cognitive restructuring will lead to a greater decrease in worry and general anxiety, while cognitive defusion will lead to a greater increase in psychological flexibility.
