E-Book, Englisch, 92 Seiten
Marker / Aylward Generalized Anxiety Disorder
1. Auflage 2012
ISBN: 978-1-61334-335-7
Verlag: Hogrefe Publishing
Format: EPUB
Kopierschutz: 6 - ePub Watermark
E-Book, Englisch, 92 Seiten
Reihe: Advances in Psychotherapy - Evidence-Based Practice
ISBN: 978-1-61334-335-7
Verlag: Hogrefe Publishing
Format: EPUB
Kopierschutz: 6 - ePub 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.
Earn 5 CE credits for reading volumes of the Advances in Psychotherapy book series. Click here to find out more!
Autoren/Hrsg.
Fachgebiete
Weitere Infos & Material
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
Tom Borkovec believes worry is a superficial mechanism that can be used to avoid deeper emotional content 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. Worry helps people avoid experiencing 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). Worry is a verbal process that prevents people from attending to important environmental information 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). Figure 1
Worry as cognitive avoidance. 2.2 Positive Beliefs About Worry
Worry can help someone anticipate and plan for the future Worry is thought by many people to have many positive qualities, such as aiding in anticipating and planning for bad outcomes in the future. For people with GAD, these positive qualities of worrying may be highly valued. People with GAD report that worry functions as a way to (1) avoid or prevent bad events, (2) motivate oneself to get things done, (3) prepare for the worst, (4) problem-solve, (5) distract oneself from even more emotional topics, and (6) superstitiously lessen the likelihood of bad events. Distracting oneself from more emotional topics coincides with the model of worry as an avoidance strategy (see above Section 2.1). For people with GAD, their belief in the superstitious efficacy of worry is reinforced both by the nonoccurrence of feared outcomes and those situations in which they effectively deal with the stimuli triggering their worries. Consequently, their belief that worry is positive may be strengthened, and the frequency of worries may increase (see Figure 2). However, recent research has found that inducing positive beliefs about worry does not necessarily lead to more worry (Prados, 2010). That said, this research was done on a nonclinical population, and the results may not generalize to individuals with GAD. Therefore, it is recommended that changing these beliefs be an important component of CBT (see Section 4.1.2). For example, Mary expressed that she “has to” worry because otherwise she would not effectively handle important situations. She reports that if she stopped worrying, she would not be doing all she could to avoid negative consequences. She remembers that worry has helped her plan for difficult situations in the past (e.g., taking final exams). The therapist’s role is to address this overvaluation of worry by helping the client investigate the pros and cons associated with using worry in this manner. That is, motivational interviewing techniques can be used to determine how useful worry is in the context of the negative consequences that are caused by excessive worry. Figure 2
Positive beliefs about worry leading to more worry. 2.3 Uncertainty and Worry
Individuals who experience distress in the face of uncertainty use worry to gain more certainty Individuals with intolerance of uncertainty believe that uncertainty should be avoided, and they experience uncertainty as highly distressing. Michel Dugas, Robert Ladouceur and their colleagues are responsible for much of the literature on intolerance of uncertainty and its implications for GAD. For example, their research has shown that people with GAD find it more difficult to tolerate and accept uncertainty than people without GAD (Dugas et al., 1998). They believe that this intolerance is a predisposing factor for developing GAD (much the same way that anxiety sensitivity is thought to be...
