Cognitive Behavioral Treatment of Generalized Anxiety Disorder The original version of these slides was provided by Michael W. Otto, Ph.D. with support from NIMH Excellence in Training Award at the Center for Anxiety and Related Disorders at Boston University
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Cognitive Behavioral Treatment of
Generalized Anxiety Disorder
The original version of these slides was provided by
Michael W. Otto, Ph.D.
with support from NIMH Excellence in Training Award at the Center for Anxiety and Related Disorders
at Boston University
(R25 MH08478)
Use of this Slide Set
• Presentation information is listed in the notes section below the slide (in PowerPoint normal viewing mode).
• A bibliography for this slide set is provided below in the note section for this slide.
• References are also provided in note sections for select subsequent slides.
Meta-Analysis of Randomized Anxiety Trials of CBT (within ES)
Norton & Price, 2007, JNMD
Effe
ct S
ize
(d)
Hofmann & Smits (2008) Meta-Analysis
• Meta-analysis of well-controlled trials of CBT for anxiety
• Inclusion criteria:
– Random assignment to either CBT or placebo
– The psychological placebo had to involve interventions to control for nonspecific factors (e.g., regular contact with a therapist, reasonable rationale for the intervention, discussions of the psychological problem)
Meta-Analysis of Controlled Trials of CBT (Between ES)
Hofmann & Smits, 2008, J Clin Psychiatry
Effe
ct S
ize
(g)
Gould et al., 2004 Meta-Analysis
• 16 studies
• Mean drop-out rate 11.4%
• Mean 10.1 hours of treatment
• No difference in outcome for studies allowing stabilized medications
• Maintenance of treatment gains across 6 months
Meta-Analysis of CBT – Gould et al., 2004Between Groups
Effe
ct S
ize
(d)
Specificity of Treatment(Siev & Chambless, 2007, JCCP)
• GAD CT = RT
• Panic Disorder CT* > RT
• Cognitive Therapy (CT) includes interoceptive exposure
• Relaxation Therapy (RT)
0
0.5
1
1.5
2
2.5
3
PTSD OCD SAD Panic GAD Agor
Meta-Analyses of Effectiveness Studies(Within ES) (Stewart & Chambless, 2009, JCCP)
Effe
ct S
ize
(d)
Comorbidity and Treatment(Newman et al., 2010)
• 76 treatment seeking adults with GAD
• 14 sessions of treatment
• 60.5% had comorbidity
• Comorbid diagnosis linked to greater GAD severity at pretreatment
• Greater change with treatment for those with comorbid depression, social anxiety disorder, specific phobia
• Normal maintenance of treatment gains
• Benefits to social anxiety disorder and specific phobia were maintained over 2 years, whereas benefits to depression were not
CBT Models of GAD (Behar et al., 2009, J Anx Dis)
• Avoidance Model of Worry and GAD– (Borkovec, 1994; Borkovec et al., 2004)
• Intolerance of Uncertainty Model – (Dugas et al., 1995; Freeston et al., 1994)
• Metacognitive Model – (Wells, 1995)
• Emotion Dysregulation Model– (Mennin et al., 2002)
• Acceptance-Based Model of Generalized Anxiety Disorder
– (Roemer & Orsillo, 2002, 2005)
Wells (1999)
• “Worry is a chain of catastrophising thoughts that are predominantly verbal. It consists of the contemplation of potentially dangerous situations and of personal coping strategies. It is intrusive and controllable although it is often experienced as uncontrollable. Worrying is associated with a motivation to prevent or avoid potential danger. Worry itself may be viewed as a coping strategy but can become the focus of …concern.”
Two Types of Worry (Dugas & Ladouceur, 2000)
• Situations amenable to problem solving
– Training in step-by-step problem solving
• Situations that are not amenable to problem solving (hypothetical problems that never happen)
– Worry times
– Worry exposure
Avoidance Function of Worry
• Worry, a verbal process, inhibits vivid mental imagery and associated anxiety (Borkovec)
• Reduces general tension and anxiety (and link stressor/panic)
• Enhances awareness about how anxiety works, de-mystifying and diminishing its impact
• Enhances self-efficacy : individuals feel equipped to cope with anxiety
Relaxation Training
• Feel the difference between tension and relaxation
• Tense 7 seconds, relax 15
• Specific muscle groups to learn the procedure
• Group them as skill increases
• Use 10-second relaxation cue
The “Words” of Worry
• Non-specific and hard to dispute
– It will be horrible
– It will be a disaster
• Downward Arrow Techniques to clarify worries and put them in a form appropriate for cognitive-restructuring
Cognitive Restructuring
• Self monitoring
• Logical analysis
• Probability overestimations
• Overestimations of the degree of catastrophe
– Ability to cope
Relapse Prevention in Depression - Metacognitive Awareness
• Classic CT and mindfulness-based CT both enhance metacognitive awareness
• Level of metacognitive awareness is linked to relapse
• Changing the relationship people have to their thoughts, rather than changing beliefs, may be important for preventing relapse
(Teasdale et al., 2002)
Mindfulness –
• Curious attention to the present moment, in an open, nonjudgmental, and accepting manner
– (Bishop et al., 2004; Germer, 2005; Kabat-Zinn, 1994)
Why Mindfulness?
• Hayes and Feldman, 2004 – Mindfulness training may enhance emotional regulation
by addressing the patterns of over-engagement (e.g., rumination) and under-engagement (avoidance) that characterizes the disorder.
– Target is a healthy level of engagement that “allows clarity and functional use of emotional responses”
• Roemer et al, 2009– Non-clinical symptoms and clinical GAD status linked to
lower mindfulness
Worry Time
• Save up the worry (cue specificity)
• End of the day worry time
• In office (non-fun) setting
• 45 min – with writing
• 10 min – relaxation skills
• Go have fun
GAD: Worry Exposure
• Metaphor: Like watching a scary movie over and over – decreased arousal and changed meaning of the worry
• Apply exposure plus response prevention (including the use of tape loops)
• The goal is elimination of the worry response via repeated exposure to core fears
• This technique should also be coupled with the prescription to worry through one topic and not switch among “spheres of worry”
GAD: Training in Normal Thinking
• Teach “normal thinking” as alternative behavior.What does one think about when not
preoccupied with worry?
• Mindfulness of thinking states that are different from worry (e.g. daydreaming, experiencing, planning, enjoying)
• Sensory awareness training
• “Staying in the moment”
• Use of “worry times”
• Limited effects of exposure on valence/preference
Attention ModificationTraining - GAD
• 29 treatment seeking patients
• Random assignment (train away vs. no train threat words)
• 8 sessions over 4 weeks
• Goal:
– Change attentional bias
– Change GAD symptoms
• Succeeded with both
– Between group effect size of .80
– Least efficacy on worry
(Amir et al., 2009, J Abn Psych)
Attention Modification Training - GAD
• Randomized clinical trial GAD (N = 29)
• Stimuli: threatening or neutral words
• 50% of those in the active attention modification program were classified as responders (no longer meeting DSM diagnosis for GAD) vs. 13% in the control condition
(Amir et al., 2009)
New Directions
• Attentional training
• Mindfulness/emotional tolerance training
• Interoceptive exposure
• Integrative treatment
GAD Interpersonal Roles
• Polarizing the relationship: the worry partner
• Improving couple’s problem-solving
Conclusions
• Nice convergence of strategies in the field
• Need to convincingly beat relaxation training as a first step in care
• Need to confirm resilience of treatment to depression (but emergent finding across anxiety disorders)
• Room for improvement – to achieve high end-state functioning