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CBT Sanderson > GAD > Flashcards

GAD Flashcards

1
Q

GAD: Brief History of DSM Diagnosis

A

1980 -­‐ DSM-­‐III -­‐ “residual” disorder characterized by hyper-­‐arousal

1987 -­‐ DSM-­‐III-­‐R -­‐ primary disorder
major revision: worry is central component

1994 -­‐ DSM-­‐IV -­‐ minor revisions remains primary disorder
worry remains as cardinal feature

2013 – DSM-­‐5
worry remains cardinal feature

  • 3 mos duration from 6 mos
  • addition of changes in behavior as a result of the worry
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2
Q

DSM-5 Checklist

A

Generalized Anxiety Disorder:

  1. Excessive or ongoing anxiety and worry, for at least 3 months, concerning two or more activities or events
  2. Restlessness And/or Muscle Tension
  3. Behavior May Be Affected by Anxiety or Worry
  4. Significant Distress or Impairment
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3
Q 
Worry 
vs
Anticipatory Anxiety
vs
Fear
A

Worry – focus on POTENTIAL future threat

Anticipatory Anxiety – focus on future threat

Fear – imminent threat

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4
Q

Pathological worry vs Normal worry

A

Frequency, intensity, duration of worry

  • excessive
  • unrealistic

Individual’s ability to control the worry

Functional impairment as a result of worry

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5
Q

Differential Diagnosis

A

Worry is a common feature of almost all anxiety disorders (e.g. social phobia, panic) as well as other disorders (e.g. hypochondriasis)

GAD dx:
Worry cannot be confined to features of another disorder

*e.g. worry about having a panic attack; worry about social situation, worry about contamination

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6
Q

GAD Comorbidity

A

93% of patients with GHD are diagnosed with at least one additional disorder

46% comorbid with major depression or dysthymia

*Estimates of 50% of alcohol abusers have prior dx of GAD

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7
Q

GAD prevalence

A

3.1% of US population (6.8 million individuals)

10% – sub-threshold GAD
“worriers”

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8
Q

Worry Functionality

A

Worry is an attempt at problem solving

Given the prevalence of worry, something so widespread must of had an adaptive function

*without worry, unable to anticipate potential negative events

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9
Q

Information Processing Model of Anxiety

A

Anxiety =

Appraisal of risk/danger
+
Appraisal of coping with the risk/danger

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10
Q

Psychopathology of GAD

A

Increased risk perception

Decreased coping ability

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11
Q

Increased risk perception

A

Information processing is driven by a core sense (schema) of vulnerability

Vulnerability leads to over estimation of risk
*both probability and severity

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12
Q

Decreased Coping Ability

A

Problem-solving is impaired, overrun by anxiety

Replaced by cognitive avoidance and safety seeking behaviors

Thus – perception of coping ability is decreased

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13
Q

GAD as Personality Disorder

A
  1. Lifelong and chronic history of anxiety with no clear onset, or onset stemming from childhood or adolescence
  2. Generalized anxiety (worry) is a very common feature of normal behavior
    * it is a basic psychological dimension that is present in everyone to some degree
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14
Q

Treatment Implications of GAD as Personality Disorder

A

More chronic may mean more treatment required

Ego-syntonic – is there a motivation to change?

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15
Q

GAD evidence-based interventions

A

Cognitive Restructuring

Worry Exposure

Stimulus – Control Procedures

Problem-Solving Training

Relaxation Training

ERP Of Behavioral Component

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16
Q

GAD assessment

A

Clinical interview

Penn State Worry Questionnaire
M = 68 SD = 9

BAI: anxious arousal

17
Q

CBT for GAD

A

Psychoeducation

Strategies to address the following components:

Cognitive

Physiological/Somatic

Behavioral

18
Q

Existential component

A

Need to develop tolerance/acceptance of risk/uncertainty

Manage risks rather than eliminate

Anxiety the shadow of intelligence? The specter of death”

19
Q

GAD Psychoeducation

A
  1. The function of worry
  2. The 4 systems/components of anxiety:
    * affect
    * physiology
    * cognition
    * behavior
  3. When is it a disorder? – Normal versus pathological worry
  4. Rationale of CBT treatment, components:
    Cognitive
    Physiological
    Behavioral
  5. Discuss role of homework and monitoring of triggers for emotional reactions (thought record)
20
Q

Rationale of CBT treatment: Cognitive Component

A

Cognitive Restructuring–logical analysis

Stimulus control – Scheduling “worry time”

Worry exposure – processing and habituation

Problem-solving training – increase coping skills

21
Q

Rationale of CBT treatment: Physiological Component

Progressive Muscle Relaxation (PMR)

A

Rationale: decrease hyperarousal

In Session: practice skills to make sure patient is implying skill properly

HW: Twice daily – Approximate 15 Minutes

22
Q

Homework

A

Explains that homework will become an integral part of treatment

To increase compliance:

Set time/day in session, give “prescription” patient

Audiotaped instructional sessions

Use a monitoring form

  • triggers for emotional reactions
  • thoughts and symptoms (thought record)

Ask patient call in or email and report results

Therapist follow-up session – problem solved noncompliance

*Never think of the patient as “resistant”

23
Q

Rationale of CBT treatment: Cognitive Component

A

Basic cognitive model: appraisal theory

Cognitive Restructuring

  • identify distorted, exaggerated thoughts that stem from the enhanced sense of vulnerability
  • have patient deliberately modify these anxious appraisals (create cognitive flexibility)

The Nature of Cognition (Information Processing):

  • Confirmatory Bias
  • Mood Congruent Processing
24
Q

Cognitive Themes in GAD

A

Stem from a core sense of

  • Vulnerability
  • Lack of control (helplessness)
25
Q

The Magic of Worry

A

Worriers fear the impact of not worrying:

Letting guard down

Superstition

BS–major challenge to tx
Sometimes even just conversation in session is too threatening–at some level, patient feels that they might be setting up future challenges to their worry–too distressing

26
Q

Cognitive Restructuring: Broad Steps

A
  1. Identify cognitions
    * automatic thoughts with discrete predictions or interpretations
  2. Examine how these automatic thoughts affect one’s emotional reactions and behavior
    * validation
  3. Subject each thought to “logical analysis” and identify cognitive distortions
    * introduce cognitive flexibility
  4. Generate a “rational response”
27
Q

Generating Alternatives

A

Automatic thoughts represent one interpretation of events

Interpretation of events is largely influenced by distorted information processing

Before assuming any one interpretation is correct, patients are asked to consider all the possibilities for generating alternative hypotheses

The strategy is intended to move patients away from the exclusive use of negatively biased information processing

*the goal is to generate as many plausible alternative explanations as possible, since psychopathological thinking is rigid

28
Q

Problem-Solving: Increasing coping when negative thoughts are accurate
Brainstorming, Pros and Cons, Solutions

A
  1. Brainstorming solutions
    * generating as many solutions as possible without stopping to evaluate them
    * encourage the patient to be creative and thorough
  2. Pros and cons
    * have the patient list the advantages and disadvantages of each proposed solution
  3. Choose the best solution and carry it out
    * have the patient consider the importance of the various pros and cons
    * based upon that analysis, choose a solution that seems best
    * take concrete steps to carry it out
29
Q

Stimulus Control and Worry Exposure

Goals

A

Decrease cues that initiate worry

Desensitize anxiety response to specific worries

Facilitate processing of worries

  • distancing
  • problem-solving
30
Q

Stimulus Control and Worry Exposure

Procedure

A
  1. Set a time and place to worry each day – 30 minutes
  2. Each time the patient has a worry, write it down and postpone worry until later
  3. Teach patient to focus attention on immediate environment as a way of distracting from the immediate worry
    * mindfulness training
  4. Patient uses worry time to focus on the worries in detail
    * encourage patient to take it to its most extreme form to maximize anxiety
31
Q

Behavioral Component

A

Exposure and Response Prevention

Focus on behaviors that ultimately maintain worry process – negative reinforcement

Avoidance

Reassurance seeking

Over preparation

Excessive checking

Procrastination

  • Identify specific behaviors and implement systematic gradual change in behavior
32
Q

GAD as “platform” disorder

A

Is GAD just Neuroticism? (more of a PD?)

It is a ‘basic’ disorder–worry, anxiety and fear are common to all anxiety disorders

By definition ‘Generalized’–can be anxiety about literally anything

33
Q

OCD vs. Worry

A

Obsessive thoughts–ritualistic and unrealistic
*very unusual, highly unlikely, and focused on a certain theme

Worry–more grounded in reality, of events that could happen

CBT Sanderson (10 decks)

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