Cognitive Behavioural Treatment for GAD
Chapter 1: Description of Generalised Anxiety
Disorder
Diagnosis of GAD
Clinical Picture: What
does GAD look like?
Worry themes
Living in the future
GAD client presentation
Epidemiology
The Cost of GAD
Chapter 2: A Cognitive
Model of Generalised Anxiety Disorder
Intolerance of
uncertainty
Positive beliefs and
worry
Negative problem
orientation
Cognitive avoidance
Implicit cognitive
avoidance
Explicit cognitive
avoidance
Connections between model
components
Chapter 3: Diagnosis and
Assessment
GAD Worry
GAD somatic symptoms
Impairment and Distress
Obstacles to diagnosis of
GAD
Differential diagnosis
Chapter 4: Treatment
Overview
Treatment Outline
Module1: Psychoeducation
and worry awareness
Module 2: Uncertainty
recognition and behavioural exposure
Relationship between
uncertainty and worry
Recognise uncertainty is
impossible to attain
Indentifying the
manifestations of intolerance uncertainty
Experiencing uncertainty
inducing situations
Module 3: Reevaluation of
the usefulness of worry
Module 4: Problem solving
training
Module 5: Imaginal
Exposure
Module 6: Relapse
prevention
Summary and Concluding
Remarks
Chapter 5: Step by Step
Treatment
Treatment Outline
Module1: Psychoeducation
and worry awareness
Module 2: Uncertainty
recognition and behavioural exposure
Module 3: Reevaluation of
the usefulness of worry
Module 4: Problem solving
training
Module 5: Imaginal
Exposure
Module 6: Relapse
prevention
Summary and Concluding
Remarks
Chapter 6 Treatment
Efficacy
Criteria for Establishing
Treatment efficacy
Studies of treatment
efficacy
General conclusions
Chapter 7: Addressing
Complicating factors
Client complicating
factors
Therapist complicating
factors
Contextual complicating
factors
Concluding remarks
Summary
Chapter 1: Description of Generalised Anxiety Disorder
Diagnosis of GAD
DSM 4 criteria
GAD is excessive worry more times than not for a period of
at least 6 months
The person finds it difficult to control worry
The person has 3 or more of the following symptoms
Restless
Being easily fatigued
Difficulty in concentrating
Irritability
Muscle tension
Sleep disturbance
The worrying produces significant stress or impairment
The difference between pathological and non-pathological
worry is the extent of worrying and the controllability of it, so it is on a
continuum. Hypervigilance doesn’t
usually accompany GAD and is more an aspect of panic disorders.
Many GAD sufferers do not seek treatment and can be affected
greatly by this, in the jobs, personal and romantic lives. Unlike other anxiety disorders GAD sufferers
don’t have visible traits to show their distress. GAD suffers can’t
concentrate, can’t enjoy what they are doing as they are worrying are less
productive. It is not such a visible distress.
Clinical Picture: What does GAD look like?
Worry themes
Worry about health and social issues are generally not gad
clients, they have health anxiety and social anxiety. GAD clients worry about a
wide range of topics. GAD clients worry
about what everyone else worries about but they also worry about more minor
topics, they also worry more excessively than non-pathological clients. GAD clients also worry about more remote and
unlikely topics.
Living in the future
Individuals with GAD often report a poor quality of life and
much of this has to do with living their life in the future, they have great
difficulty in living in the moment. Excessive future orientation prevents
enjoyment in the present, and that is where life occurs. If you purely live in
the moment then this will be debilitating as you won’t plan or prepare, or
produce things that take longer than the moment to create.
GAD client presentation
GAD clients can often not appear anxious or nervous. However
once they start to discuss their worries it will become clear. An assessment with a gad client might take
some time as they will worry in case they have left anything out. A client may well not refer to it as worrying
but rather thinking or preparing, so you may well need to use different terms
as worrying is slightly pejorative.
Clients may refer to their worries as fears. The word worry is sometimes
not used as it is seen as to not be clinically significant.
One response to manage the anxiety around worrying is
reassurance seeking.
Clients can often be high functioning but quite impaired in
terms of quality of life.
Epidemiology
Epidemiology is the study of the distribution and
patterns of health-events, health-characteristics and their causes or
influences in well-defined populations
2% suffer from GAD, and 5-7% will develop it during their
lifetime.
There are two periods when GAD develops 11-20 and middle
adulthood, so hmm 30-40. In early onset the increase in responsibilities plays
a part, and in late onset there is a significant life stressor such as death
that precipitates GAD.
GAD symptoms rarely abate over time, unlike maybe
depression.
GAD is more common amongst women. GAD is common in the 65-75
age range.
GAD is highly comorbid, with mood disorders and dysthymia
being the most popular.
The Cost of GAD
GAD is often misdiagnosed as it can be masked by other
comorbid conditions and also doesn’t have visible symptoms, therefore many
years of inappropriate treatment can be undergone. GAD affects work
productivity
Chapter 2: A Cognitive Model of Generalised Anxiety Disorder
Cognitive model of GAD has four aspects
1.
Intolerance of uncertainty
2.
Positive beliefs about worry
3.
Negative problem orientation
4.
Cognitive avoidance
Intolerance of uncertainty
This is the belief that uncertainty is stressful and
upsetting. This is the belief that being uncertain about the future is unfair,
unexpected events are negative and should be avoided and that uncertainty
impairs one from functioning.
Relaxations techniques can be useful but GAD clients reach a
plateau after early successes and then are still left with GAD.
Standard cognitive restructuring around anxiety is about
probability and decatstrophising, so to move from the possibility that
something might happen to its probability and the ability to manage should the
worst happen. However with GAD clients
even knowing there is a 1 in a million chance can allow them to hang on to
worrying. GAD clients almost want
absolute certainty that other anxiety sufferers don’t.
There is a high correlation between intolerance of uncertainty
and worrying.
One pathway from uncertainty to worrying is that with GAD
clients given 2 or more outcomes they will believe a negative outcome will
ensue.
Pathways from intolerance to uncertainty to GAD
GAD clients tend to exaggerate threatening interpretations
of ambiguous information. GAD clients may well have strongly held beliefs about
uncertainty, leading to the threatening interpretations. Thus when faced with uncertainty, there is a
level of threat that creates anxiety, that then the GAD seeks to counteract.
High worriers also take longer to reach a decision where
there are higher levels of ambiguity.
Higher worriers require greater evidence when there is higher ambiguity
than do lower worriers. Highly ambiguous
situations are difficult for most people, however in moderately ambiguous situations
then people who are intolerant of uncertainty perform more poorly than non-clinical
people. Thus as GAD clients need more
information in moderately ambiguous situations then this may lead to prolonged
worry and anxiety about the situation.
Beliefs about uncertainty in GAD are fully activated when
there is a negative mood. When anxious GAD clients have less confidence in
making a decision in ambiguous situations which may lead to worry about the
implications of their decisions.
So GAD clients
1.
When faced with an ambiguous situation make
threatening interpretations
2.
GAD clients worry and this impacts on the amount
of information needed for decision making
3.
GAD clients get anxious and thus require longer
to get confidence about taking a decision
Positive beliefs and worry
1.
Worrying can prevent negative outcomes
2.
Worrying is a positive action for finding a
solution to a problem
3.
Worrying increases motivation to get things done
4.
Worrying in advance can decrease ones reactions
to things should they actually occur
5.
Worrying’s shows that one is a responsible and
caring person
Positive beliefs about worry are not specific to GAD clients
but to all anxiety clients. The degree
to which clients believe these statements is relative to the degree with which
they worry.
Negative problem orientation
Problem solving can be broken down in to two major constituents:
1.
Problem orientation
2.
Problem solving skills
Problem orientation refers to an individual’s cognitive set
when faced with a problem. Perception of problem, seeing yourself as a problem
solving agent and expectations regarding problem solving outcomes, so i.e. what
do problems mean to you, can you solve them, how big is the problem etc.
Problem solving skills refer to:
1.
Defining the problem
2.
Generating alternative solutions
3.
Choosing a solution
4.
Implementing a chosen solution and monitoring
its effectiveness
GAD suffers have difficulties around problem orientation and
generally not around problem solving skills.
Thus the third component of GAD is a negative problem
orientation, the three then are:
1.
Intolerance of uncertainty
2.
Positive beliefs about worrying
3.
Negative problem orientation
Negative problem orientation most strongly affected the
decision making step in problem solving in the non-clinical population and for
GAD suffers then it affected all problem solving steps.
Cognitive avoidance
Cognitive avoidance refers to avoidance aimed at cognitive
and emotional content. There are two aspects of cognitive avoidance, implicit
and explicit.
Implicit cognitive avoidance
When people worry they do so without mental imagery. Mental
images play a key role in the generation of the fear response, so worry
supresses these.
According to emotional processing theory, then fear reduction theory then fear is reduced
when the full fear structure is accessed in memory and some information that is
incompatible is integrated into this structure.
GAD then is negatively reinforced by reducing mental images
and the fear and autonomic arousal associated with that.
Explicit cognitive avoidance
1.
Suppressing worrisome thoughts
2.
Substituting neutral or positive thoughts for
worries
3.
Using distraction as a way to interrupt worry
4.
Avoid situations that can lead to worrisome
thinking
When you try to suppress thoughts then you get both an
enhancement effect when you can’t stop thinking about it and also a rebound
effect when you think about it intermittently over the next few days.
The thought suppression effect of enhancement and rebound, i.e.
when you try to stop thinking about something it enhances the number of times
you think about it, and you think about it at random times after that, is a
central aspect in thought difficulties in all anxiety presentations.
Cognitive avoidance dampens the initial fear reaction but
then through enhancement and rebound effects doesn’t eradicate but in fact
increases it, which then requires more cognitive avoidance, and so on.
The other pathway that avoidance uses is the GAD client’s
negative belief about anxiety. GAD
clients tend to fear their own anxiety responses. Again this means they don’t
learn how to deal with their anxiety or challenge the negative beliefs
underneath them.
Connections between model components
There are four aspects of GAD
1.
Intolerance of uncertainty
2.
Positive beliefs about worry
3.
Negative problem orientation
4.
Cognitive avoidance
The higher order aspect is intolerance about uncertainty in
that it contributes to all other aspects, as it creates the anxiety that the
others respond to.
Chapter 3: Diagnosis and Assessment
GAD has the lowest clinical assessment reliability. GAD
shares its DSM criteria with a lot of other anxiety disorders, but the key is,
is their worry excessive and uncontrollable.
GAD Worry
Assess the client’s life stressors first, this can help
ascertain whether the worry is disproportionate to the event. It is also important to ask about positive
things that have recently changed in a client’s life as this can be a cause of
worry.
To try to gauge the excessiveness of worry, go through all
the major areas of a person’s life, relationships, family, money, job, health,
social life and minor life matters to see what the level of worry has been over
the last six months. Then ask them if
they worry too much about these matters.
Likewise ask if everything is going alright with things that might have been
a stressor, so find out if its stress or not that that causes worry, and a GAD
client would continue worrying irrespective of event. Again compare their worries to others, if a
good friend had the same things happen to them, do you think they would worry
as much. This will assess the
excessiveness of a person’s worries.
Then you need to assess the uncontrollability of their
worries, so ask the client do you worry about worrying, do you feel it out of control.
Likewise is worry chained, so I worry about a car accident and how I would
cope, then how the children would cope, and where they would end up? Does your
worry feel like a freight train, once it’s started you don’t feel that it can
stop.
GAD somatic symptoms
You need three of the six to qualify
1.
Restlessness or feeling keyed up all the time
2.
Being easily fatigued
3.
Difficulty concentrating
4.
Irritability
5.
Muscle tension
6.
Sleep disturbance
To qualify there needs to be this symptom for more days than
not over a 6 month period.
So whilst the above apply to many diagnoses then you need to
ask further about why they can’t sleep, why they can’t concentrate, and if its
worry that is mentioned, then its GAD.
Impairment and Distress
Firstly you can ask them what the level of impairment is,
however they may think they are born worriers, so not know. In that instance
ask how worrying effects their relationships, their job, their ability to enjoy
life.
Obstacles to diagnosis of GAD
Few clients will present with excessive worry as their
complaint as worry is not seen as a legitimate complaint. Clients present with fears and phobias which
when interrogated can show to be worry. To describe worry it is building
scenarios of negative events, what happens if x, then x, then y and what will I
do, it builds a scenario out of uncertainty and it is all negative. A GAD client may worry about getting the
right diagnosis so offer exhaustive detail of their situation, they may well
endorse questions from other anxieties, e.g. social anxiety. You need to explain the difference between
experiencing the symptom and having the symptom as a problem, or they will
endorse all symptoms as everyone has them, but only the clinical population
have them as problems.
Differential diagnosis
The difference between GAD and health anxiety, is the former
is worried about the possibility of getting cancer, the latter thinks they have
it already. GAD clients are less likely
to have a catastrophic misinterpretation of a change in their body, where health
anxiety people would.
Social anxiety clients worry about making a fool of
themselves and avoid situations. GAD clients just worry about these situations
but don’t worry about making a fool out of themselves specifically and don’t
avoid.
The difference with OCD is OCD can have compulsions or
rituals, but not all the time. Obsessions are intrusive thoughts as are
worries, the difference between the two is obsessions tend to be about odd or
sexual things, whereas worries are far more every day. Obsessions can take the
form of images or impulses, whereas worries are always verbal. OCD has static worries, whereas GAD is
dynamic.
The difference between the rumination of depression and GAD
is that ruminators focus on negative past events, whereas GAD focuses of
possible negative events in the future, which is my friends where possibility
lies. GAD clients can worry about past events but only in terms of their future
repercussions, whereas ruminators use past events to show what a failure they
are.
Chapter 4: Treatment Overview
Treatment Outline
Core target is the worry not it’s by products, e.g. feeling
keyed up, tense etc., relaxation exercises don’t target the cause. The aim here is to create a greater tolerance
for uncertainty. With worry there is scenario building of potential outcome in
order to control uncertainty and be fully prepared for each threatening
outcome. One way to do this is to get
clients to be familiar with uncertainty and their reactions to it. So an exposure style approach is used where uncertainty
is sought out whilst refraining from safety behaviours. The positive beliefs a client has about
worries are shown, and then they are encouraged to engage in problem solving
and not worrying.
Module1: Psychoeducation and worry awareness
Psychoeducation about CBT
·
CBT shows
bidirectional relation between thoughts and behaviours and emotions
·
CBT shows that we learn to have problems and
that they are not the direct result of genetics or the unconscious
·
CBT is a collaboration, I’m not going to cure you,
but we are going to work together, as you are an expert in your life, and it is
unique and I am an expert in theory
·
CBT provides tools to enable the client to
independently enhance their life
·
CBT is brief and time limited and teaches the
client to become their own therapist
·
CBT is based on the here and now and focuses on
factors that contribute to maintaining the problem, identifying the origins of
the problem do not solve it
·
Thoughts are beliefs not facts!!!!
Psychoeducation about GAD
·
GAD is excessive and uncontrollable worry about
a number of events
·
Causes somatic problems
·
It’s not a disease to be cured but exists along
a continuum from the normal to the pathological
·
GAD is maintained by the clients, thoughts and
behaviours, present this model in its entirety so as components are introduced
the road map is already understood and can be made sense of
Worry awareness training
Get clients to start identifying
different types of worry
Two categories
1.
Worries about current problems
2.
Worries about hypothetical situations
Module 2: Uncertainty recognition and behavioural exposure
This lays the groundwork for future modules and should not
be rushed.
Ensure client sees
·
relationship between intolerance of uncertainty
and excessive worry
·
uncertain situations cannot be avoided
·
the various manifestations of intolerance of
uncertainty, i.e. their excessive worry, their anxiety reaction
·
Certainty is impossible to attain
Client also needs to seek out uncertainty inducing
situations
Relationship between uncertainty and worry
A client needs to be shown that research shows that
intolerance of uncertainty is the best predictor of GAD and that what GAD tries
to do is to prepare for every possible outcome, but this is only because they
cannot tolerate uncertainty.
Recognise uncertainty is impossible to attain
GAD clients attempt to achieve certainty to reduce their
worries. In intolerance of uncertainty, there are two aspects intolerance and
uncertainty. The GAD client attempts to deal with this by trying to turn
uncertainty into certainty, but Socratic dialogue should open up the
impossibility of this. CBT deals with the intolerance.
Identifying the manifestations of intolerance uncertainty
Clients use many behavioural and cognitive strategies to
deal with uncertainty. These attempt to
circumvent the feelings associated with uncertainty, i.e. fear. They are either
approach or avoid strategies. Approach
strategies are to seek reassurance and obtaining excessive information before
making a decision. Avoidance strategies seek to avoid the uncertain inducing
situations, so don’t accept the promotion as you don’t know what it will be
like, put off doing the assignment until the last minute so the feelings of
uncertainty are minimised.
Experiencing uncertainty inducing situations
So the exposure here, would be for example
1.
Not rereading low priority emails before sending
them
2.
Not seeking reassurance prior to making minor
decisions
3.
Add some variety to routine, as routine is an
attempt to be certain
Module 3: Re-evaluation of the usefulness of worry
As clients present with GAD then you’d think they may not
have any positive beliefs about worry, however generally the reinforcing
behaviour or worry includes following the rules of living which are the
positive beliefs about worry
Positive beliefs about worry
1.
Helps find solutions to problems
2.
Shows I care
3.
Prepares for the future
4.
Motivates and helps get things done
5.
Can prevent negative outcomes
These positive beliefs are not erroneous, as non-clinical
people hole them too, but GAD sufferers hold them to a stronger aspect, such as
only through worrying can I find a solution to my problems for instance. Indeed as with worry which can be useful, but
its usefulness decreases the more excessive it gets.
Clients present with something of a paradox, generally they
want to reduce their anxiety caused by worry, but they don’t want to stop
worrying about specific situations.
Clients need to think about what it means to worry less, so
remember the time when you didn’t worry as much, this can be very difficult as
they may have worried for as long as they can remember. So important to bring up fears and feelings
with changing the extent you see your old friend worry.
So the stages here are firstly surface the positive beliefs
around worries, and then ask where the evidence is that there beliefs are
cached out, i.e. does worrying help you find a solution?
Module 4: Problem solving training
Problem solving training focuses on problems that are
current not on hypothetical ones! Problem solving is action orientated. There
are two aspects here, problem orientation and problem solving skills. Generally
GAD clients have good problem solving skills and a poor problem orientation.
Improving problem orientation
There is uncertainty in problem solving so it is aversive to
GAD sufferers. The uncertainty is when you act, knowing how it will turn out,
knowing whether or not you made the right choice.
Problems need to be effectively defined and solutions need
to be realistic. The aim working through uncertainty is to achieve the best not
the perfect outcome, or even a better outcome than you have currently, to make
an improvement to a problem is a success!
Negative problem orientation causes problems, if a client is
threatened by a problem, doubts their ability to solve it and anticipates a
negative outcome of any attempt to solve the problem then they will react with
negative cognitions and affects and not want to solve the problem. Thus instead of being active and facing the
problem they become passive and worry about it instead.
As problems become unsolved so they in turn generate other
problems, so the inactivity of worry is self-fuelling.
Problem orientation needs to be addressed before looking at
problem skills as the latter won’t be used unless there is some optimism in the
former. Learning problem solving skills
is not about learning the skills as generally everybody has them, but rather in
terms of using them effectively. So improperly defining a goal, setting an
unrealistic solution is more likely to be the problems here.
Clients need to tolerate uncertainty here and move from one
step to the next without having a perfect of certain definition of that step,
improving is a good word here. You can never predict an outcome, and an ability
to manage an adverse outcome, a mistake is a really good learning mechanism for
uncertainty tolerance.
Module 5: Imaginal Exposure
Here there is the introduction of exposure to hypothetical
situations, situations where problem solving isn’t appropriate. Problem solving
training deals with interpersonal uncertainty, where there are current problems
in the world, i.e. externally driven. Imaginal exposure deals with internal
uncertainty where there is a projection into the future situation and there is
fear around this, and worry is the response.
The theory here is that worry is negatively reinforced by
cognitively avoiding distressing images.
Cognitive avoidance is as follows:
1.
Avoidance of mental imagery by using worrying
(implicit avoidance)
2.
Attempts to suppress worrisome thought
3.
Attempts to replace worrisome thoughts by
pleasant or neutral thoughts
4.
Attempts to use distraction to stop the worry
process
5.
Avoidance of situations that might trigger
worrisome thoughts
Imaginal exposure is also useful for GAD clients as they
tend to jump from one topic to another. With GAD exposure it is important to
retain a level of uncertainty in the image, to make it ambiguous.
Module 6: Relapse prevention
When therapy ends it can be difficult for clients. To ease
this then to foster skills in the clients gives them independence. Clients can
also be unaware of their success, as there is rarely epiphany but rather a
gradual change and development
Chapter 5: Step by Step Treatment
Module1: Psychoeducation and worry awareness
Presenting the principles of CBT
Present CBT theory and process, as ever to present it socratically
and not didactically is the way. So Socratic teaching of the relation between
thoughts, behaviours and emotions. So you’re frightened of dogs, you see a dog
what do you think what do you do. So
thoughts influence behaviour and emotion. As you cross the street what are you
saying to yourself how do you feel. So as much as thoughts influence emotions,
so behaviours can influence both thoughts and emotions. CBT makes use of this
relationship and helps you understand your problem in a new way.
Presenting homework socratically.
You are an expert in your life, I am an expert on
understanding problems in new ways and teaching skills, thus we need to work
together to be most effective. I will also be asking you to do assignments
between sessions to practice new skills or test out new ideas, why do you think
this is important? Before you answer imagine you went to learn the piano so you
sign up for 12 hours of lessons, what kind of piano player would you be if you
only played the piano for 12 hours a week. Whenever you learn something new be
it playing the piano, or learning new ways to manage your anxiety or live then it’s
only through repeated practice that you will learn these skills
Explaining GAD
This normalise, explain the excessive and uncontrollable
nature of it, how it is on a continuum from normal worry and how for it to be
GAD it lasts for more than 6 months.
Look at somatic problems as being results of worry. You might want to
explain the difference between the categorical and continuum model, i.e. either
you have gad or you don’t, or you exist on a continuum, where a point on the
continuum is considered to be GAD
Presenting things in a stepwise fashion prevents a client
from being overwhelmed.
So GAD is triggered by an event, or memory and you think
what if or wouldn’t it be terrible if, can you think of examples of your own.
However the cycle doesn’t end there, and on top of the scenario you build for
the what if, comes another what if, can you think of an example of this. Some
of these thoughts are worries and are set in motion by what if questions and
they start to form a chain.
Definition of worry= worry is a thought process about a
future event where there is uncertainty about the outcome but there is anxiety
it will be a negative outcome. Worries can be triggered by internal and
external events. So you might see something on the news and this creates the
what if questions, or there might be an internal event, such as feeling tight
in your chest. There are also two different types of worries, worries about
current events and about future events. The latter haven’t happened and may
possibly never happen. We distinguish
between these two different types of worry as we have different strategies with
each.
What is the consequence of worry, standardly anxiety and its
concomitant somatic symptoms, or rather physical sensations of tension, knotted
stomach, difficult to get to sleep etc.
Worry is a type of thought and anxiety is a type of emotion,
we know that thoughts influence emotions, so if we can manage these thoughts
better we can change the emotions that follow from it. The effect of chronic worrying is
demoralisation and fatigue.
Worry awareness training
You need to be able to spot when worrying happens to be able
to modify it.
Whilst there may be resistance as clients think they already
think too much about their worries, this assignment is prescribed and they are
asked to fill out a worry diary and classify their worries. When the diary comes
back its time to ask what the client found out.
Typically clients don’t worry about everything but worry
about themes. Some worries will last for minutes some for hours, but it’s
important to see how much time is being used to worry in. Worries will involve future events, even if
triggered by a historic event.
Module 2: Uncertainty recognition and behavioural exposure
It is vital that the client sees their worry as a reaction
to uncertainty. So first of all they need to recognise uncertainty, and their desire
to make it certain by worrying.
So you can describe intolerance to uncertainty like a
psychological allergy. Again you can
think of intolerance being like wearing uncertainty glasses so you see
uncertainty in areas where other people don’t so you are more responsive to it
. So you see uncertainty more frequently and all the bad things that can come
out of it.
The manifestations of intolerance of uncertainty
The client here needs to become familiar with all their
strategies to deal with uncertainty. So
ask the client how they deal with uncertain situations. GAD use worry to try to feel more certain
about a situation, even though it doesn’t change the situation. Some people ask for reassurance or seek
excessive amounts of information about something, or delay doing something
until the last minute so they don’t have to feel uncertain about it for longer
than is necessary, is this something that you do
Manifestations of intolerance of uncertainty
Approach strategies
1.
Wanting to do everything yourself, as otherwise
you can be certain it is done right
2.
Looking for a lot of information before doing
anything
3.
Questioning a decision you have made as you are
no longer certain that it is the right one
4.
Looking for reassurance
5.
Rechecking things you did as you are not certain
you did them correctly
6.
Overprotecting others from doing things
Avoidance strategies
1.
Avoiding fully committing to certain things
2.
Finding imaginary reasons for not doing things
3.
Procrastinating
Intolerance is the fuel for worry, to deal with intolerance
of uncertainty, there are two options increase certainty or increase tolerance.
Check how the client’s strategy has been working. Check why increasing
certainty is not a viable option. Uncertainty is unavoidable, no matter how
much we plan our lives something unexpected always comes up. In order to change
a belief, then it’s best to start with changing your behaviour. If you think I can’t
speak in public, then rather than sit and try to convince yourself that you
can, best to do it, to keep on doing it, until you see that you can speak in
public. Likewise with uncertainty if you
act as if you are tolerant of uncertainty, after a while you will become more tolerant
of uncertainty and then change your beliefs.
So the client gets homework of a low level tolerance of
uncertainty, examples include:
1.
Send a low priority email without rereading it
or checking it for spelling errors
2.
Take a minor decision without asking for
reassurance
3.
Go to a movie or restaurant without checking for
reviews
4.
Call a friend unexpectedly and ask them out to a
social gathering.
Suggestions when facing uncertainty
1.
Record the experiment, how you expected it to
go, and how it actually did go
2.
Starts small and realistic
3.
Expect to be anxious or uncomfortable
4.
Motivation does not precede action, it follows
it. If you wait to be motivated to do something you could be waiting a long
time, if you start doing it, then the motivation to continue will follow.
Module 3: Re-evaluation of the usefulness of worry
Clients may feel reluctant to discuss their positive beliefs
about worry as they hold them illogically i.e. I want to stop worrying but I
think worrying is useful. So they might dislike worrying in general but find
some specific worries to have a positive intention.
Identifying positive beliefs about the usefulness of worry
Introduce the 5 common positive beliefs about worries, get
the client to identify their positive beliefs before challenging them
Worrying:
1.
Finds solution to problems
a.
This is true for low level worry, but high level
worry shows how all our solutions might fail
2.
Motivates to action
a.
Here worrying about something gets confused with
caring about something. However worrying leads to inactivity and increases
anxiety and if you stop worrying it wouldn’t mean that you became complacent
3.
Protects a person from negative emotions
a.
In other words prepares you for any
disappointment, GAD becomes like putting money in the bank, a safeguard.
However when a negative event does happen then having worried or not doesn’t
make it any better.
4.
Prevents negative outcomes
a.
This is thought action fusion. However its
logically flawed and has selective attention, as positive outcomes have
happened without worry, check childhood for examples if necessary
5.
Represents a positive character trait, i.e. care
a.
Do you know anyone who cares but doesn’t worry?
The client then needs to complete a diary where they
indicate what positive beliefs are being used. Then use guided discovery and where’s
the evidence to find out whether their positive beliefs are true.
Strategies for re-evaluating positive beliefs about worry
Here there is a fine line between allowing a client to
express their views without judgement and challenging these. Again a client
might see logically there to be a flaw in their actions but feel them to be
right. Clients might think surfacing
their positive beliefs, is preventing treatment, or showing ambiguity in
something they want to change, again these ideas should be explored.
Lawyer-Prosecutor Role-play
Client focuses on a specific worry they have then take on
the role of lawyer and convince the jury of the usefulness of worry. Then they take on the role of prosecutor who
argues that worry isn’t useful. You can
use Socratic questioning on the prosecutor side to elicit further arguments, do
you know anyone who cares but doesn’t worry.
As you challenge beliefs, always do it in the context of a
specific worry.
Re-evaluation of positive beliefs: a life without worry
As the usefulness of worry recedes, clients can feel sad
through wasting their time and want to know what to do instead, problem solving
can be an answer here. Problem-solving is active, worrying is passive.
Challenges to positive beliefs about the usefulness of worry
1.
Worry aids problem solving
a.
Do you solve problems or merely go over them in
your head, is this wheel spinning
b.
Do you actually solve problems, or get so
anxious you avoid doing anything about them
2.
Worry motivates
a.
Do you know anyone who is successful and doesn’t
worry
b.
Are you confusing worrying and caring about
something
c.
Does your worry improve performance, what are
the outcomes of worrying
3.
Worrying protects against negative outcomes
a.
Has anything bad happened to you that you
worried about, did it make it any better
b.
Does worrying about things that never happened
cause negative feelings in the here and now
4.
Worrying prevents negative outcomes
a.
Have you ever had a negative outcome when you
have worried
b.
Have you ever had a positive outcome when you
haven’t worried
5.
Worry is a positive personality trait
a.
What are the attributes of a caring person
b.
Do you know anyone who cares but doesn’t worry
c.
Have you ever suffered any negative consequences
with the people you care about because of your worry, i.e. has anyone not liked
your worry
6.
The cost of worry, i.e. challenging all worry beliefs
a.
Has excessive worrying impacted your
relationships
b.
Has it affected your work performance
c.
Has it led to stress and fatigue
d.
How much time do you spend on it, do people who
worry less perform better
Look at ways in which the client could use their time if
they weren’t worrying
If a client shows no positive beliefs around worrying it
could be classical conditioning, so you may want to ask if anyone they grew up
with worried a lot, or if they can remember the first time they worried
excessively.
Module 4: Problem solving training
This is split into two aspects, improving problem
orientation and applying problem solving skills. The client can replace
excessive worry with problem solving and this should be emphasised. Worrying is
a passive activity, although clients may initially think it is active, problem
solving is active, and productive and can make things feel better. Problem
solving deals with current worries, imaginal exposure deals with hypothetical
worries. Can be useful to say research shows that excessive worriers have good
problem solving skills but have a negative problem orientation, that is they
have more negative attitudes about problems and problem solving skills.
People with a negative problem orientation
1.
View problems as threatening
2.
Doubt their ability to solve problems
3.
Believe that problem solving will turn out badly
Can be useful to get a client to do a 5 aspect on negative
problem orientation beliefs.
Thoughts
Negative problem orientation
Emotions=Frustration, irritation, anxiety and depression
Cognitive consequence, worry about problems
Behavioural consequences=avoidance, procrastination and
impulsive problem solving. Impulsive problem solving means you have to worry
less about it.
Having a negative problem orientation means that problems
can be avoided and then can mount up, and increase the levels of problems that
then can’t be faced and then worry comes in. If clients have an intolerance of
uncertainty then a negative problem orientation is a natural outcome, why well
as soon as uncertainty comes up there is a strong reaction, so the problem
seems bigger than it otherwise is and seems threatening.
Strategies for Improving problem orientation
Three aspects to this
1.
Recognise a problem before it’s too late
2.
Seeing a problem as part of normal life
3.
Seeing problems as opportunities rather than
threats
Recognise a problem before it’s too late
Being problem aversive means you can avoid problems and then
they begin to grow and become more serious and complex.
To help with this then there are two strategies
1.
Using emotional cues
2.
Creating a problem list
Emotional cues:
Many clients interpret their stress or frustration as the
problem, but rather they are the by-product of the problematic situation, so
when you feel anxious or stressed, look to see what this is a by-product of.
This will also help you see your negative emotions in a more positive light, as
they are signs to something being wrong.
Get the client to write a problem list, often we act with
surprise and disappointment when a problem comes up as if it happened for the
first time but these problems come up again and again. So keeping a list can help you see what come
up again and again, so you can see what are important to solve, and likewise it
will reduce the anger and disappointment as you will be used to seeing them,
again it helps you see where you should direct your energy as what the most
important ones are .
Seeing problems as a normal part of life
People with a negative problem orientation tend to feel
resentful when they have problems as they see problems as abnormal. Thus
problems are attempted to be eliminated through avoidance or worry but this is
futile as we all have problems. Some people see them having problems as a sign
of incompetence, but we all have problems.
Seeing problems as opportunities rather than threats
In our lives we tend to avoid threats and to approach
opportunities, it is important to get the client to approach their problems. Whilst there is a threat within a problem,
there can also be seen an opportunity.
Problems , events do not need to be put into either threats or
opportunities, rather they lie on a continuum. So with any problem ask yourself what the
opportunity is within it, does it motivate you to do something better for
yourself. Opportunities can be acquiring
new skills, building relationships, making your life better for yourself, do x
enables you to do y as you don’t have to worry about x
Applying problem solving skills
GAD clients often have a problem moving from one step to the
other. They find uncertainty in each step, not solving it perfectly.
Problem definition and goal formulation
To solve a problem one must properly define it. Some clients
offer one problem, but it turns out to be many problems stuck together.
A good problem definition is
·
Defined in clear and concrete language
·
Based on facts not assumptions
·
Be able to answer
o
What is the situation
o
What would I like the situation to be
o
What is the obstacle that is interfering with
the attainment of the desired situation
·
Focussed on the central conflict. When one has
control over the situation then behaviour should be the target, when one
doesn’t then emotions should be the target.
·
Shouldn’t be too narrow in scope, i.e. how do I
write 5 reports in one hour, should be how can I write reports more efficiently
Goals should be
1.
Concrete
2.
Attainable
3.
Time aware, when do I need to achieve it by
a.
Long term goals can be demotivating so setting
sub goals is important
Generation of alternative solutions
This is the brainstorming stage, put an idea down without
criticism. The obstacles to this are habit and convention, so surface these
obstacles and get the client to think outside habit and convention, what would
a friend do, what would a crazy person do, what would a flamboyant person do…etc.
Three principles of brainstorming
1.
Defer judgement
a.
Suspend all judgement whilst creating ideas
2.
Quantity
a.
Generate at least 10 possibilities
3.
Variety
a.
Aim to get as much variety as possible, so the
underlying idea behind an idea should be different, and not just be variant
Once the list has been created then it can be refined, so
turn the abstract into concrete ideas, then look to choose the best one, or
combination of the best ones, or modification of the silly ones.
Decision making
This is often very hard for gad clients as they want the
perfect solution not the best they can at this time.
So the solutions from the brain storming list need to be
evaluated via the following questions
1.
Will it solve my problem
2.
How much time and effort are involved
3.
How would I feel if I used this solutions
4.
What are its consequences, both short and long
term for myself
Run through the list and see which option has the best fit
with the above four questions.
Solutions Implementation and verification
This can be uncertain as there is no guarantee that a chosen
solution will have the desired outcome.
Clients should plan the steps to achieve their solution and
be wary of meticulousness that avoids doing! Again the client should set up
markers to verify their solution is working. Putting in markers early lets you
know whether a plan is not working early so you can do something about it. If
it wasn’t troubleshoot the various steps you took to arrive at the problem and
the solution to see where the gap is.
The therapist will also be faced with uncertainty, possibly
unexpected outcomes and failures, and it is good to model how these should be
approached.
Steps to effective problem resolutions
1.
What is the problem, i.e. what is the current
situation and how would you like it to be different and what obstacles are in
the way
2.
What goal would you like to achieve is it
realistic and achievable
3.
What are all the possible solutions to the
problem, come up with quantity and variety
4.
What is the best, not perfect solution and
answer these questions
a.
Will it solve the problem
b.
How much time and resource is involved
c.
How would you feel if you use this solution
d.
What are the consequences of this solution both
short and long term
Module 5: Imaginal Exposure
This is to learn how to deal with worries for hypothetical
situations, situations that haven’t happened and may never. Here the aim is to
expose the clients to feared mental images that they cognitively avoid. Because this is difficult for the client then
the rationale behind it must be fully explained
The futility of cognitive avoidance
Illustrate how cognitive avoidance is counterproductive
through the enhancement and rebound effect.
So introduce the white bear example: sit for sixty seconds, don’t think
of a white bear, not even the word, any time you think of white bear raise your
hand, how many times did you think of a white bear yesterday or last week. So
why did you think of it when I told you not to.
Then explain the enhancement effect and rebound effect. So when you have an unpleasant image if you
try not to think about it, or try to make it better through worrying about it,
then it increases the number of times that you think about it, and it affects
you.
Explaining avoidance
If we are dog phobic then we would cross the road if we see
a dog, how would that make us feel, however what is the problem with this.
However it’s not just avoidance that maintains anxiety it’s
also neutralisation. So if I decide to
tackle my fears then go to my friend’s house who has a dog, , however once
there I get very anxious and then start to look out of the window, what do you
think happens to my anxiety? This is an
example of neutralisation. If you stay in a feared situation for long enough without
avoiding or neutralising it, then your anxiety goes down.
Trying not to think about something happening in the future is
avoidance.
Worrying about something happening in the future is
neutralising.
Preparing the exposure
1.
Identify the theme of exposure
2.
Prepare a draft scenario
3.
Finalise the scenario
4.
Record the scenario for repeated exposure
Identifying the exposure them
To do this use a downward arrow.
So if you’re frightened of a plane crashing then ask what
would happen next. If you go too far in
the downward arrow then the client might say it’s too farfetched in which case
then you need to go back one step in the downward arrow.
Preparing a preliminary draft of the exposure scenario
The scenario should be in the present tense in the first
person and should contain as much detail as possible and without any neutralisation. The scenario should last between a minute and
five minutes. So as the scenario unfolds
ask is this what you are afraid of, is this likely to happen in this scenario
Finalizing the scenario
If a client uses I imagine, then it’s not real, use the
present tense and the first person, I see, I do etc.
Recording the scenario for repeated exposure
Get the script read slowly so the emotional resonance can
come through.
Conducting exposure
The first exposure should be carried out in the therapist’s
office as it will be scary for the client.
It also takes some time to sit with the anxiety and tolerate it until it
dissipates. The therapist should then instruct
to score their anxiety every minute to see how their anxiety changes. Clients should then practice every day, and
get used to the anxiety curve, of the anxiety going up then coming down.
Exposure should be continued until you get habituation and
there is no anxiety when shown the feared object.
Module 6: Relapse prevention
There are three aspects of this:
1.
Daily maintenance
2.
Noticing at risk situations
3.
Preparing for at risk situations
Daily maintenance
What got them better can keep them better, so continuing
problem solving and exposing where necessary will keep them well. The aim of therapy is that the skills taught
become unconsciously used, so disputing the positive beliefs in worry, problem
solving, tolerating uncertainty and imaginal exposure.
Identifying at Risk situations
See what your triggers are, and see that you will encounter
fluctuations in symptoms during this time but these are only a problem when
they are interpreted catastrophically. When they see an increase in symptoms
use this as a red flag to do more practice on their skills.
Preparing for at risk situations
Remember the difference between a lapse and a relapse and
how it’s the reaction to a lapse that will indicate whether or not it will be a
relapse.
Chapter 6 Treatment Efficacy
Haven’t read this chapter as it has no interest for me
currently
Chapter 7: Addressing Complicating factors
Client complicating factors
Sorry couldn’t get excited about reading this one, talks
about comorbidity and complications with medications
Therapist complicating factors
A therapist needs to adapt their treatment to the client’s
needs. Clients will be low in confidence about therapy so the therapist needs
to have high confidence, but this does not mean that every treatment is going
to work or be successful, so the therapist should model the same kind of
problem solving attitude they are trying to see to their client.
Manualised treatment approaches can be useful as they are
tried and tested approaches, but their application must be individualised to
the client.
Summary
Ok so GAD is excessive and uncontrollable worry which both
comes from and leads to anxiety and produces somatic problems.
GAD comes from an intolerance of uncertainty, where
ambiguity is see as threatening and worry attempts to control all the possible
outcomes. The domains of worry are about current events and future events. Worry serves to reduce the fear that may be
attached to a future image as images are more fearful than words, worry also
seeks to solve the bind of wanting to fix uncertainty with action but realising
that problem solving is itself inherently uncertain, as the desired outcome might
not realise. So given the positive beliefs that worrying can provide solutions,
motivation, preparedness for feared outcomes and potentially prevention of the
feared outcome, and that problem solving is uncertain, worrying is taken as the
solution of choice. Worrying is then cognitively avoidant of the feared thought
of hypothetical uncertainty and also of the uncertainty of problem solving. The
treatment then follows the following course
Treatment
1.
Psychoeducate about CBT, worry and the worry
model, do a worry log
2.
Show how the client has intolerance of
uncertainty
a.
Look at worries from the worry log and see what
themes come up
b.
Do the intolerance of worry questionnaire
c.
Explain that intolerance of uncertainty is the
fuel for worry and worry attempts to cover all outcomes
d.
Find out client strategies to deal with uncertainty
3.
Surface the clients positive beliefs on worry
and challenge them socratically
4.
Engage in problem solving for current problems
5.
Show how exposure works, engage in imaginal exposure
