generalised anxiety disorder update

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generalised anxiety disorder update
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babcp conference spring 04I cant get it out
of my head
investigating/treating unwanted intrusions
ruminations

• eight speakers
• variety of disorders
• tom borkovec gave the keynote talk on
  GAD and worry
• next day, a choice of several workshops
• I went to toms on adding emotional
  interpersonal elements to GAD CBT treatment

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I contacted tom after the workshop usa visit?

• he was hugely welcoming helpful
• so last autumn I flew off to to penn state
  university for a week
• ... and hence this buzz session today

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tom borkovec

• professor of psychology at penn state
  university
• twenty years of fine research to improve our
  understanding treatment of GAD
• his penn state web page lists 30 articles
  book chapters published (or in press) in the
  last 3 years
• of particular buzz for me are two research
  developments in his work
• one is the his exploration of what the severe
  normality of GAD can tell us about normal
  mind states

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...the other is his research on adding emotional
interpersonal components to the cbt treatment
of gad

• Borkovec, T.D., Newman, M.G., Pincus, A.,
  Lytle, R. A component analysis of cognitive
  behavioral therapy for generalized anxiety
  disorder and the role of interpersonal problems.
  J Consult Clin Psychol 2002 70 288-298
• Borkovec, T.D., Newman, M.G., Castonguay, L.G.
  Cognitive-behavioral therapy for generalized
  anxiety disorder with integrations from
  inter-personal and experiential therapies. CNS
  Spectrum 2003 8 382-389
• Newman, M.G., Castonguay, L.G., Borkovec, T.D.,
  Molnar, C. Integrative therapy for generalized
  anxiety disorder. In R.G. Heimberg, C.L. Turk,
  D.S. Mennin (Eds.), Generalized anxiety disorder
  Advances in research and practice, pp. 320-350.
  New York Guilford Press, 2004
• Castonguay, L. G., Newman, M. G., Borkovec, T.
  D., Holtforth, M. G., Maramba, G. G. (in
  press). Cognitive-behavioral assimilative
  integration. In M. Goldfried J. Norcross
  (Eds). Handbook of psychotherapy integration.
  Oxford Oxford University Press

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why is gad important?

• high prevalence office of national statistics uk
  reported in 2000 that besides a catch-all
  mixed anxiety depressive disorder diagnosis,
  GAD at a current prevalence of 4.4 is the most
  common neurotic disorder more common than
  depressive episode, phobias, OCD, or panic
• considerable morbidity GAD is associated with
  considerable suffering reduced quality of life,
  major increases in GP consultations health care
  costs, and extensive time off work
• chronicity a systematic review found that only
  25 would be in full remission at 2 year and
  only 38 at 5 year follow-up
• comorbidity GAD is highly comorbid with other
  disorders such as major depression, but the GAD
  tends to predate and increase vulnerability to
  the subsequent comorbid disorder
• the basic anxiety disorder Professor David
  Barlow has written that GAD may be the basic
  anxiety disorder, with increased understanding of
  GAD having implications for all anxiety disorders

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gad worry, anxiety tension
frequent distressing worry thats difficult to
control about many things that might go wrong in
the future
restlessness, irritability, muscle tension,
fatigue, difficulty concentrating, and sleep
disturbance
more freeze than fight or flight thoughts
more than images, unhappy but not strongly in
touch with emotions, or with the present moment
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successful cbt approach for gad

• self-monitoring for early signs of
  anxiety and tension
• training in calming skills, application
  during daily life, and coming into
  the present
• using imaging to encourage use of
  calming skills and cognitive coping
  strategies
• cognitive coping strategies include
  worry tree, worry outcome diary, worry problem
  solving times, worry-free zones, beliefs about
  worry, etc

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... but better results welcome

• despite getting as good results as any other
  research team, post treatment 50 of clients are
  still not within normal range
• in tom borkovecs third major research study
  using CBT for generalized anxiety (GAD III), it
  was found that having more interpersonal problems
  predicted a less successful response to CBT
• it was already known that worry at times acted as
  avoidance of images emotions
• the IIP questionnaire suggested possible
  difficulties in current relationships, and there
  were frequent problems in upbringing and
  relationships with parents as well

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for GAD IV, added I/EP to CBT
plus deepening emotional inter- personal conta
ct with self others
plus living more to our own inner values
plus focus on the present moment
cbt involving applied relaxation, imagery methods
various cognitive challenges
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the components of interpersonal emotional
processing therapy
the penn state I/EP therapy focuses on

• relevance of upbringing
• traumatic events with others
• unresolved earlier relationships
• nature of current friendships
• other role relationships e.g.
  work, couple, parent, etc

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its high time for a broader integration of
interpersonal emotional components into cbt

• Coyne JC. Thinking postcognitively about
  depression. In Freeman A, Simon KM,
  Beutler LE, Arkowitz H, editors. Comprehensive
  handbook of cognitive therapy. New York Plenum,
  1989. p 227-44
• Gotlib IH, Hammen CL. Psychological aspects of
  depression towards a cognitive-interpersonal
  integration. Chichester John Wiley, 1992
• Safran J, Segal Z. Interpersonal process in
  cognitive therapy. Northvale, NJ Jason Aronson,
  1996.
• Castonguay LG, Goldfried, M.R. et al. Predicting
  the effect of cognitive therapy for dep-ression
  a study of unique and common factors. J Consult
  Clin Psychol 199664497-504.
• Hayes AM, Castonguay LG, et al. Effectiveness of
  targeting the vulnerability factors of depression
  in cognitive therapy. J Consult Clin Psychol
  1996 64 623-7.
• Safran J, Muran JC. Negotiating the therapeutic
  alliance. New York Guilford Press, 2000.
• Klein DN, Schwartz JE, et al. Therapeutic
  alliance in depression treatment controlling for
  prior change and patient characteristics. J
  Consult Clin Psychol 2003 71 997-1006.
• Greenberg LS. Emotion-focused therapy.
  Washington, DC Am Psych Assn, 2002.
• Castonguay LG, Newman MG, Borkovec TD, Holtforth
  MG, Maramba GG. (in press). Cognitive-behavioral
  assimilative integration. In M. Goldfried J.
  Norcross (Eds). Handbook of psychotherapy
  integration. Oxford Oxford University Press