Advances In The Treatment Of Generalized Anxiety Disorder

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Advances In The Treatment Of Generalized Anxiety
Disorder
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Diagnostic Criteria

• Excessive anxiety uncontrollable worry about a
  number of situations, causing interference or
  marked distress
• Not focused on other Axis I issues
• At least 3 of the following 6 associated symptoms
• Restless, keyed up, or on edge
• Easily fatigued
• Difficulty concentrating
• Irritability
• Muscle tension
• Sleep disturbance

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Importance of GAD

• Fairly high prevalence and a very frequent
  co-morbid disorder
• May be the basic anxiety disorder
• GAD therapy eliminates majority of co-morbid
  disorders

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Comorbid Conditions at Pre-therapy and Follow-Up
in GAD II and GAD III
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Nature of GAD

• Central feature Worry (cognitive anticipation of
  threat)
• Therefore, Cognitive Therapy makes sense

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• Worry has incubating properties
• Therefore, early cues detection makes sense

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Worry involves a predominance of thought (as
opposed to images) Self-report evidence EEG
evidence
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Worry prevents emotional processing during
repeated imaginal exposures
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Worry prevents emotional processing during
repeated in vivo exposures
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• Therefore, use imagery methods

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Worry functions as cognitive avoidance and is
negatively reinforced in several ways -
Reduction of somatic anxious experience -
Beliefs about the positive functions of
worry
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1) Clients often hold certain beliefs that
worrying serves a useful function. 2) So it is
important in therapy to identify whether a client
holds any of these beliefs and to work with the
client to replace them with alternative beliefs
or approaches. 3) Otherwise, our attempts to
reduce worry will be in the face of sometimes
strong negative reinforcement contingencies, real
or imagined.
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Positive Beliefs About Worry

• Preparation
• Avoidance/Prevention
• Superstition
• Motivation
• Problem-Solving
• Distraction from More Emotional Topics
• (See Appendix A)

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Central CognitionThe world is a dangerous
place, and I wont be able to cope with it, so I
have to anticipate possible threats. Lost in
illusions of the future and the
past Fight-or-flight with no place to go
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Central Physiological Effects- High muscle
tension- Autonomic inflexibility- Vagal tone
deficiency
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State and Trait Vagal Deficiencies Are Likely Due
To Worry (GAD II-Thayer)
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Therefore, Relaxation Techniques make sense
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Explains DSM-IV Changes in Associated
Symptoms Criteria Retained Deleted Keyed
up Palpitations Concentration
Nausea Irritability Lump in Throat Muscle
Tension Hot/Cold Flashes Restlessness
Urination Sleep Disturbance Trembling Fatigue
Sweating Dry Mouth Deleted
Dizziness Startle Dyspnea
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Central Behavioral Effects -
Subtle behavioral avoidances and inhibition-
Procrastination- Lack of spontaneity
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Little Joy in Life, Given Focus on the Illusion
of the Dangerous Future and Absence of
Present-Moment Experience(Pink Floyd - The
Wall)
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Emotional Reactions In Kids Adults
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GAD and Heart Rate Reactions to Positive and
Negative Stimuli (Aikens)
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• Self-Monitoring and Early Cue Detection
• Anxiety as a spiraling process over time
• Importance of reactions to reactions

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Catastrophic Images/Thoughts
/ \ Perception Defensive
Behavioral Of Threat -gt Response
-gtAvoidance/Inhibition -gt Memory
\ Somatic /
Activation/Inhibition
-------------------------------------------------
----------------
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Monitoring All Response Levels

• Advantages of early cue detection
• Practice in-session (Use 0-100 point scale)
• Practice in daily living

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Relaxation Methods

• Slowed, paced diaphragmatic breathing
• Abbreviated progressive muscular relaxation
• Relaxing imagery
• Meditation

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Applied Relaxation in-session and in daily
living

• Multiple relaxation methods
• Flexible application to early anxiety cues
• Exposure homework for coping rehearsals before,
  during, and after events

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Special Approaches for GAD

• Yerkes-Dodson curve
• The problem of trying to relax (relaxation-induced
  anxiety) movement toward tranquility
• Past and future is always an illusion anxiety is
  always one of these
• Discovery Watching for what cognitions,
  feelings, and behaviors will emerge from
  tranquility
• Present-moment focus of attention

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Focusing Effects On Anxiety Among Socially
Anxious Folks (Przeworski, 2003)
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Self-Control Desensitization Imagery
is important for

• Accessing affective meaning and providing
  exposures to and processing of emotional material
  that is otherwise avoided
• Strengthening coping responses through efferent
  command
• Processing positive information and strengthening
  new beliefs at the effective level

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Procedure Client Generates Anxiety Through
Imagery, Then Imagines Relaxing Away the Anxiety
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Homework Assignment Practice After Each
Relaxation Practice

• Allows for repeated opportunities to rehearse
  flexible coping responses in response to internal
  cognitive (especially worry) and somatic anxiety
• - Incorporate cognitive coping statements and
  perspective shifts derived from cognitive therapy
  sessions
• End with image of most likely outcome

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Later SCD Approaches - Informal SCD
- Surprise images - A day in the life of
client images
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Stimulus Control of Worry

• Establish a 30 minute worry period
• Detect early onset of worry
• Postpone worry to the worry period, using
  letting-go responses and perspective shifts, and
  focus attention on present moment or task at hand

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Use worry period

• To worry intensely
• To distinguish worries over which you have some
  control versus those over which you do not
• To problem solve or create adaptive perspectives
  using cognitive therapy methods

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Basic Cognitive Therapy
(Briefly)Demonstration that thoughts influence
affect (the illusion of threat)Identification
of automatic thoughts and underlying
beliefsQuestion the validity of thoughts and
beliefs thoughts as hypotheses
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Logical Analysis (Briefly)

• Probability and evidence
• Advantages and disadvantages of this perspective
• Feelings as fact and as evidence
• Questions to ask yourself (See Appendix B)

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Distancing the Client
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Generation of Alternative (Multiple and Flexible)
Perspectives and Possibilities
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Special Cognitive Therapy Techniques With GAD

• Process all present-moment information
• Process positive information imaginally
• Intrinsic versus extrinsic motivation (process
  rather than outcome)
• Internal versus external consideration in social
  situations
• The relativity of bad events
• Could rather than Should
• The consequences of perfectionism

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Decatastrophizing

• To identify underlying fears for logical analysis
• To establish conditional probabilities
• To determine coping responses for each eventuality

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Special emphasis on worries

• Worry Outcome Diary New history of probability
  and evidence
• Write down detected worries as they are noticed
  during the day
• Also write down what outcome you fear will happen
• When an outcome occurs for a worry, rate whether
  it was worst than expected, as bad as expected,
  or better than expected. Rate also how well you
  coped with the outcome on the same scale.

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Behavioral Experiments

• To test hypotheses
• To provide extinction and coping response
  application opportunities

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Early Cue Detection and Flexible Perspective
Shifting, and Use of Cognitive Products in
Self-Control Desensitization
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Arguments in Cognitive Therapy
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Expectancy-Free Living (Zorba, The Greek)
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CBT Interventions Yield 50 High Endstate
Functioning
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Within-Group Effect Sizes For Prior CBTs
Component Conditions For GAD III
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Are There Core Fears In GAD For Exposure
Techniques?

• The Future
• Intolerance Of Uncertainty (Dugas)
• Meta-Worry (Wells)
• Fear Of Emotions
• Interpersonal Fears

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The Role of Interpersonal Factors in GAD
Close connection between GAD and social
evaluative fear -Worry correlates most highly
with social evaluative fears - The largest
percentage of worry topics fall into the
interpersonal domain - Social phobia is the
most frequent comorbid condition - Worry is
thinking thinking is verbal and for
communication
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Attachment and GAD

• Role-reversed enmeshed relationships with primary
  care giver (Cassidy, 1995)
• Predominance of Disorganized Insecure Attachment
  (Cassidy, 2005)
• Normalized after treatment

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Attachment Classifications (Cassidy)
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Current Interpersonal Pattern Factors Cluster
Analysis of Inventory Of Interpersonal Problems
(Pincus, 1994) 62 Overly Nurturing and
Intrusive 26 Nonassertive and Socially
Avoidant 12 Domineering and Vindictive Interpers
onal problems predict outcome in GAD III
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Interpersonal/Emotional Processing Therapy
(IEP)

• Goals To facilitate client identification of
  interpersonal needs and fears, and to help client
  to develop better interpersonal behaviors to
  satisfy those needs
• Draws from CBT, Interpersonal Therapy, and
  Experiential Therapy, viewed within a CBT
  theoretical orientation
• (See Appendix C for relevant process research
  findings)

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Assumptions Underlying Our Interpersonal/Emotional
Processing Therapy Manual (IEP) (Michelle Newman)

• Clients habitually avoid painful emotions
  (including positive emotions)
• So busy avoiding what they fear from others that
  they fail to pursue their needs
• Protect themselves from negative reactions of
  others
• Avoid letting others know who they are and what
  they feel (Vulnerability)

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• The therapeutic relationship (feedback and
  modeling) can be a powerful opportunity for
  learning about self and others

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Functional Analysis of Interpersonal Variables

• Core inaccurate beliefs and interpretations about
  interpersonal situations and impacts on self and
  others
• Core interpersonal needs based on identification
  and experiencing the underlying primary emotions
• Fears and avoidance behaviors about those needs
• Nonadaptive interpersonal strategies to attain
  those needs

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In Functional Analysis, Attend to Possible

• Developmental origins of schemata (attachment
  relevance)
• Traumatic events with others
• Unresolved prior relationships
• Nature of current friendships
• Other role relationships (e.g., occupational,
  parental, marital)

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• Sequential Questions For Functional Analysis Of
  Interpersonal Events
• What event happened between you and the other
  person?
• What emotions did you feel?
• What did you need or hope to receive from the
  other person?
• What did you fear from the other person?
• What did you do?
• How did the other person respond?
• What did you feel and how did you respond to that?

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General Techniques and Presumed
Mechanisms(Exposure, Feedback, Modeling, and
Skills Training)

• Exposing clients to feared emotions
• Providing feared feedback about their impact on
  others
• Providing feedback on their fear of being
  vulnerable if they show who they really are
• Teaching more empathic attention to the emotions
  and needs of others
• Teaching more effective interpersonal behaviors
  in order to better satisfy interpersonal needs
• Directing attention away from anticipating danger
  and toward openness, spontaneity, and
  vulnerability (Intrinsic Approach)

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IEP Methods

• Exploration of out-of-session interpersonal
  relationships and experiments between sessions
• Accessing and modifying cognitive processes in an
  emotionally immediate way
• Moment-to-moment attention to what is emotionally
  alive for the client
• Use of interpersonal markers for
  cognitive/affective exploration

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IEP Methods

• Use of the therapeutic relationship for exploring
  cognitive/affective processes and challenging
  interpersonal schemata
• Use of therapists own feelings to generate
  hypotheses about clients interpersonal patterns
• Importance of detection and resolution of
  ruptures in the therapeutic alliance
• Social skill training

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Process Effects Theoretically Important
Processes Predict Outcome Within Both Segments of
Therapy
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Within-Group Effect Sizes For Prior CBTs And For
CBT/IEP (GAD IV)
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• Current Additive Trial (GAD V)
• 14 two-hour sessions
• CBT CBT/IEP
• 1st Hour CBT CBT
• 2nd Hour Supportive IEP
• Listening

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Within-Group Effect Sizes forCBT/SL CBT IEP
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Percentage Of Clients Scoring Within Normal Range
On All IIP Scales (GAD V)
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Within-Group Effect Sizes Over Consecutive Studies
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Appendix APositive Beliefs About Worry

• Preparation
• Avoidance/Prevention
• Superstition
• Motivation
• Problem-Solving
• Distraction from More Emotional Topics

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1) If I worry about something, when something
bad does happen, Ill be better prepared for
it. (Preparation)

• Supported by evidence of muted somatic activation
  in response to fear images
• Consider cost/benefit and alternatives
• ABAB experiments

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2) If I worry about something, I am more
likely to actually figure out how to avoid or
prevent something bad from happening.
(Avoidance/Prevention)

• Worry outcome diary
• ABAB experiments

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3) Although it may not actually be true, it
feels like if I worry about something, the
worrying makes it less likely that something
bad will happen. (Superstition)

• Worry outcome diary
• ABAB experiments

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4) Worry helps to motivate me to get things
done that I need to get done. (Motivation)

• ABAB experiments
• Consider positive reinforcement procedures to
  motivate behavior

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5) Worrying is an effective way to
problem-solve. (Problem-Solving)

• Distinguish problem-solving from worrying
• Distinguish worries over which you have some
  control and those over which you do not
• Stimulus control program and using its worry
  period for problem-solving or especially applying
  cognitive therapy skills

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6) Worrying about most of the things I worry
about is a way to distract myself from worrying
about even more emotional things, things that I
dont want to think about. (Distraction from
More Emotional Topics)

• Does GAD have a core fear of set core fears?
• Fear of emotions in general?
• Fears inherent to interpersonal relationships and
  not having needs met there?
• Therefore, emotional deepening and interpersonal
  therapy have a potential role

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Appendix BQuestions to Ask Yourself

• What am I saying to myself about this situation?
• How am I seeing or interpreting this situation?
• What does this situation mean to me?
• What must I believing to be true?
• What am I predicting will happen?
• What images come to mind?
• What is the threat or danger?
• What are the advantages and disadvantages to this
  way of seeing things?

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• What is the probability of the bad things
  happening?
• What evidence do I have that this might happen?
• How often have such bad things happened in the
  past?
• Is this a logical way to think?
• How many other people would see it this way?
• What kinds of good outcomes have happened in past
  situations like this?
• Am I confusing feeling with fact?
• How can I test this way of predicting or
  believing?
• How well have I coped with such bad things in the
  past?
• What coping resources do I have if bad things
  occur?
• Whats the worst that could happen? Would I cope?
• What would I tell a good friend who has the same
  worry?

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Appendix CProcess Findings Related To
Interpersonal Issues

• In contrast to psychodynamic therapy, focus on
  interpersonal functioning does not relate to
  outcome in CBT
• CT therapists focus on clients cognitions about
  others is negatively related to outcome
• CT therapists attend less to real interpersonal
  difficulties, but attention to such difficulties
  relates to positive change
• CBT focus on developmental issues relates
  positively to change
• CT therapists do not pay much attention to issues
  emerging between themselves and the client, but
  when they do, clients benefited from it
• Compared to psychodynamic therapists, the
  emotional reactions of CT therapists intrude more
  on the therapeutic process
• While the quality of alliance predicts outcome in
  CT, the CT techniques used to address alliance
  ruptures can interfere with clients improvement