E-Book, Englisch, 92 Seiten
Marker / Aylward Generalized Anxiety Disorder
1. Auflage 2012
ISBN: 978-1-61676-335-0
Verlag: Hogrefe Publishing
Format: PDF
Kopierschutz: 1 - PDF Watermark
E-Book, Englisch, 92 Seiten
Reihe: Advances in Psychotherapy - Evidence-Based Practice
ISBN: 978-1-61676-335-0
Verlag: Hogrefe Publishing
Format: PDF
Kopierschutz: 1 - PDF Watermark
A practical book outlining a new, evidence-based treatment protocol for this debilitating and difficult-to-treat disorder
Generalized anxiety disorder (GAD) is a debilitating disorder that has often proved difficult to treat. Advances in conceptualization, diagnosis, and treatment now allow an empirically supported approach to its diagnosis and treatment. After briefly outlining theoretical models, this clear and concise book presents an integrative, up-to-date treatment protocol for GAD. Suitable both for practitioners and for students, it guides readers through assessment and differential diagnosis, etiological models such as cognitive avoidance, positive beliefs about worry, and intolerance of uncertainty, and treatment techniques. The therapeutic approach described here integrates techniques from CBT, mindfulness- and acceptance-based therapy, as well as motivational interviewing. This practical volume is rounded off by case vignettes, handouts, questionnaires, and other useful tools.
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Autoren/Hrsg.
Fachgebiete
Weitere Infos & Material
1;Preface;6
2;Table of Contents;8
3;1 Description;10
4;2 Theories and Models of Generalized Anxiety Disorder;21
5;3 Diagnosis and Treatment Indications;29
6;4 Treatment;38
7;5 Case Vignette;59
8;6 Further Reading;66
9;7 References;67
10;8 Appendix: Tools and Resources;74
If this measure is elevated following treatment, it might be a cause for concern due to the possibility for relapse.
Metaworry
Meta-Worry Questionnaire. The Meta-Worry Questionnaire (MWQ; Wells, 2005) is a 7-item questionnaire that measures beliefs about worry (see also Section 2.5). It is derived from the 65-item Meta-Cognitions Questionnaire (Cartwright-Hatton & Wells, 1997). The 7 items are scored on a 4-point Likert scale (range of each item is 1 to 4). This questionnaire has been found to be reliable and to discriminate worry in GAD from somatic anxiety, as well as to discriminate individuals with GAD from those with other disorders (Wells, 2005). This measure is best suited for assessment prior to beginning treatment. It might also be used to assess change in this potential predisposing factor.
GAD Symptoms
Worry and Anxiety Questionnaire. The Worry and Anxiety Questionnaire (WAQ; Dugas, Freeston, et al., 2001) is an 11-item questionnaire that assesses diagnostic criteria of GAD (based on the DSM-IV). Items are rated on a 9-point Likert scale (items range from 0 to 8). This measure may be suitable for a screening measure, but a clinical interview is warranted because the WAQ will often lead to false positives.
1.7.3 Assessing Suitability for Treatment
A person with GAD will typically have suffered with excessive worry for some time before seeking psychological treatment. Although this suffering provides great motivation to work on the symptoms of GAD, CBT requires that the client also be willing to engage in treatment and “buy into” the techniques. If someone has many positive beliefs about worry, then he or she might not be as willing to make changes to his or her worry as someone who has some negative beliefs about worry. As the CBT model is presented, the therapist should carefully assess the person’s willingness to engage in treatment. One does not always expect the person to be fully ready for treatment. However, a person who expresses major concerns that the treatment will not work may be much more resistant to trying it. Assessment of the individual’s previous attempts at dealing with the excessive worry is also important. It is vitally important to maintain the client’s motivation for treatment. A common technique used to enhance motivation is to have the client consider the disadvantages and advantages of continuing to use worry as a strategy. Because many people feel that there are positive benefits to their worry, it is also important to identify these benefits. However, listing the negative consequences will highlight the tremendous difficulties that come from the excessive worry.
2 Theories and Models of Generalized Anxiety Disorder
This chapter covers a number of models that have been proposed to explain how GAD, and more specifically worry, develops and how it is maintained. Each of these models has been substantially supported by research. These models cover three basic components of worry: predispositions to worry (one’s intolerance of uncertainty and positive beliefs about worry), perceptions of threat (information-processing biases), and reinforcers of worry (worry as cognitive avoidance and metaworry). For the most part, these models are complimentary in that they can fit together within an overarching framework in which each model explains an important element in the origin or maintenance of excessive worry. This section presents the descriptions of each model followed by an attempt to integrate these models into one comprehensive model, which is presented at the end of the chapter. To illustrate these models, some case examples are included. Chapter 5 also includes a case vignette describing Laura, a 36-year-old mother of two, who was diagnosed with GAD.
2.1 Worry as Cognitive Avoidance
One model of GAD, originally posited by Thomas Borkovec and colleagues, posits that worry is used as a means to avoid threatening cognitive and emotional content. Although this model may be counterintuitive at first, it posits that worry has an important function for people with GAD. Specifically, worry is thought to be a linguistic process that does not tap into deeper mental images (and thus anxiety related to these images). Thus, worrying does not allow deeper emotional processing. To say it another way, worry is used to avoid processing an emotional experience completely. Although the worry is troubling to the person with GAD, it may actually be serving as a way for the person to process negative information on a superficial level with less emotional intensity and distress. The person can avoid some of the negative emotions associated with the worry if he or she processes it only linguistically and without mental imagery. Indeed, studies have found that people who were worrying did not create imagery; rather worry was experienced as a negative verbal/linguistic activity (e.g., Borkovec & Inz, 1990). Additionally, Vrana, Cuthbert, and Lang (1986) found that people verbally articulating fear material created much less heart rate activity than when imagining the same frightening situation. Moreover, individuals have reported that they use worry to avoid more distressing topics (Borkovec & Roemer, 1995). Thus, worry is thought to only activate the verbal linguistic network and may be less distressing than other negative emotions.
In this model, worry is viewed as a negative reinforcer. Just as taking an aspirin gets rid of a headache, worry gets rid of negative emotions. Often, these negative emotions arise from a previous worry. Thus, the person may jump from worry to worry without fully processing any worry. In the short-term, the person feels relief from not experiencing the anxiety at a deeper level. However, in the long-term, worry inhibits the person from emotionally processing the information (see Figure 1). In addition, because of the reinforcement associated with worrying, the person may actually worry more. Thus, for people with GAD, worry is a paradox. The worry has short-term benefits of reducing negative emotion, but the worry has long-term consequences of causing greater distress. There is also some indication that people may be more susceptible to this process if they have greater intolerance for dealing with negative emotions. Thus, assessment of how one copes with negative emotions may also be important (see also the AAQ-II in the subsection “Emotional Avoidance” in Section 1.7.2). An important treatment implication stemming from this model is that a person with GAD may benefit from processing negative emotions more deeply to reduce levels of worry in the long-term (see also Section 4.1.3).
Additionally, others have also highlighted that verbal processing impedes other environmental and experiential information from being processed (e.g., Roemer & Orsillo, 2002), which can prevent the learning of nonthreatening associations. Hayes, Strosahl, and Wilson (1999) purport that verbal processes initiate behavior through verbal contingencies rather than contact with contingencies that are present in the environment. Consequently, individuals may be relying on verbally rule-based behaviors while the environment presents contradictory information. Moreover, behavior that is verbally rule-based can be very resistant to disconfirming environmental evidence and will thus persevere (Hayes & Ju, 1998). As a result, worry prevents the extinction of fear because experiential avoidance is reinforced and the verbal-linguistic processes prevent experiential disconfirming associations from being learned.
For instance, let’s consider a client, Mary, who came into treatment complaining of constant anxiety. She reports that she is “terrified of feeling anxiety” as soon as she wakes up in the morning and does “whatever I can to avoid it.” She reports that she worries “all the time.” And indeed, in session, she cannot seem to focus on detailing one worry but rather “jumps” from worry to worry. The therapist has a hard time focusing Mary because so many threatening worries are coming to her mind. When the therapist asks Mary if she ever focuses on the frightening images associated with one worry, she states, “I couldn’t bear doing that” and “I avoid picturing anything related to my worries.” Mary notices that she worries all the time, and she reports that she deliberately avoids focusing on the frightening images associated with her worry. Moreover, she feels that she is totally unable to control the constant worry she experiences. Mary’s treatment will focus on helping her process these emotions more fully through the use of exposure (i.e., exposure to her worries).
