worry, anxiety & tension

1. worry, anxiety & tension generalised anxiety disorder update

2. babcp conference spring ’04“I can’t 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 tom’s on adding emotional & interpersonal elements to GAD CBT treatment

3. 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

4. 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

5. ...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

6. 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

7. gad: worry, anxiety & tension frequent distressing worry that’s 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

8. 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

9. ... 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 borkovec’s 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

10. for GAD IV, added I/EP to CBT plus deepening emotional & inter- personal contact 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

11. the components of interpersonal & emotional processing therapy • relevance of upbringing • traumatic events with others • unresolved earlier relationships • nature of current friendships • other role relationships e.g. work, couple, parent, etc the penn state I/EP therapy focuses on:

12. it’s 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 1996;64:497-504. • 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 Ass’n, 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