Cognitive Behavioral Treatment for Generalized Anxiety Disorder

From Science to Practice

Melisa Robichaud, Naomi Koerner, Michel J. Dugas

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781317486855
• Edition: 2
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

The second edition of Cognitive Behavioral Treatment for Generalized Anxiety Disorder is an essential read for all clinicians, researchers, and anyone who wants to learn about how cognitive behavioral therapy (CBT) can be applied to treatment for generalized anxiety disorder.

Building on the idea that intolerance of uncertainty keeps people with generalized anxiety disorder (GAD) stuck in repeated cycles of excessive worry, anxiety, and avoidance, this revised and updated edition lays out the essentials of GAD assessment and diagnosis, step-by-step illustrations of CBT treatment, and questionnaires and monitoring forms that can be used in assessment, treatment, and research.

Readers will come away from the book with a clear sense of how to:

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• design powerful, individualized behavioral experiments targeting the fear of uncertainty;

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• help clients discover and re-evaluate their beliefs about the usefulness of worry;

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• encourage clients to view worry-provoking problems as challenges to be met, rather than threats;

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• use written exposure to help clients confront lingering worries and core fears.

Chapter 1

Description of Generalized Anxiety Disorder

Catherine was the first of three children. During her childhood, she had often been reminded that, as the eldest child, she should look out for her two younger siblings. By the time Catherine reached the third grade, she had begun worrying about her younger brothers. For example, if it was raining, she worried about whether one of them might catch a cold, or if they played rough games, she worried whether one of them might injure himself. She would often check on them several times a day to make sure that they were safe or to see if they needed anything. Although her worrying was not a problem, she was clearly less carefree than most of her friends. In high school, Catherine succeeded very well in academics and athletics. She always had good grades and was a member of the swimming and track teams. Despite worrying less about her younger brothers, she noticed that she had begun to worry more about the health of her parents, in particular her mother. For example, she had started calling her mother at work, sometimes several times a day, to ensure she was all right. Again, although Catherine did not feel that her worrying was a problem, she had definitely noticed that moderate levels of worry and anxiety were something she often had to deal with.

It was only when Catherine went away to college that her worry and anxiety began to get noticeably out of hand. Being away from home, she found herself worrying more than ever about her family. She had also begun to worry about other things such as her grades, financial situation, and friendships. She started having trouble sleeping, often lying in bed for hours before finally falling asleep. Although she continued to do well in school, she found that preparing for exams was extremely stressful, and this would typically result in Catherine speaking to her teachers or classmates several times to ensure her course notes were correct. In addition, writing papers seemed to take longer than usual because Catherine would read over what she had written several times to reassure herself that she had made no spelling or grammar mistakes.

After college, Catherine began a successful career in marketing, and eventually got married and had two children. Following the birth of her second child, her worry and anxiety began to “spiral out of control,” and she decided that it might be time to receive some type of treatment. She described experiencing nearly constant feelings of fatigue, insomnia, and anxiety about “anything and everything.” She also noted that these feelings were beginning to interfere with her family and work life. Although she loved her children very much, she was so worried about their health and safety that she was usually tense and on edge while spending time with them. She found this to be extremely distressing, and she said that she could no longer enjoy happy moments in her life because she was so worried about any negative events that might take place in the future. She was also beginning to feel overwhelmed at work, yet she refused to delegate any responsibilities to other employees, stating that she could only be sure that the work was “done properly” if she did it herself.

Catherine was skeptical about the benefit of any form of psychological treatment, since she thought she had “the worrying gene” and was unlikely to change this part of her character. However, she was tired of “always feeling stressed out and anxious” and was willing to try anything to stop feeling this way. When she presented for treatment, she received an in-depth assessment. Based on her report of excessive worry about a number of daily life events, and her endorsement of somatic symptoms such as fatigue, sleep difficulties, and feelings of restlessness, she was given a diagnosis of generalized anxiety disorder (GAD).

As can be seen from the preceding illustration of Catherine, GAD can easily become quite debilitating, and can greatly reduce one’s quality of life. Unfortunately, people afflicted with GAD rarely seek professional help, and when they do, clinicians often have difficulty recognizing the symptoms as being those of GAD. For these reasons, we will attempt to accomplish two major goals in this introductory chapter. The first is to provide a relatively thorough description of the characteristics of GAD. Specifically, we will discuss the history of the diagnostic category, the prevalence and associated features of the disorder, and the impairment that GAD typically engenders. The second goal is to present a “picture” of what GAD looks like from the clinician’s point of view. What do we mean when we say “excessive worry and anxiety about a number of events or activities?” What is daily life like for someone with GAD? The above description of Catherine is only one example of the many ways in which GAD clients can present for treatment. It is our hope that, by thoroughly presenting information gathered over the course of our clinical practice, we can begin to provide a detailed picture of this fascinating and complex disorder.

Diagnosis of GAD

Generalized anxiety disorder is a diagnostic category that has undergone several changes within different editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 1980, 1987, 1994, 2000, 2013). As such, it should come as no surprise that the diagnosis of GAD is at times confusing, even for anxiety disorder specialists. In the following section, we will review the evolution of GAD in the DSM, we will describe the changes that have been made to the criteria, and we will discuss the reasons behind these changes. The reader will likely note that while the current diagnostic definition in recent editions of the DSM is greatly improved from earlier editions, there is still much work to be done to arrive at a set of clear and reliable criteria that will increase the ease with which GAD is diagnosed.

History of the Diagnostic Category

The term GAD first emerged with the publication of the DSM-III (American Psychiatric Association, 1980). At that time, GAD was essentially viewed as a residual disorder because the diagnosis was not made if symptoms of panic disorder, obsessive-compulsive disorder, or phobias were present. The fundamental feature of the disorder was “persistent anxiety” for at least one month, with clients also required to endorse symptoms from three out of four categories, including motor tension, autonomic hyperactivity, apprehensive expectation, and vigilance/scanning.

To improve upon the broad and vague nature of the DSM-III diagnostic criteria for GAD, several important changes were made with the DSM-III-R (American Psychiatric Association, 1987). First, the core feature of the disorder shifted from persistent anxiety to excessive or unrealistic worry. Moreover, GAD could now be diagnosed in the presence of another mental disorder, so long as the worry and anxiety were unrelated to the other condition, thereby changing GAD from a residual problem to a primary diagnostic entity. The minimum duration required for a diagnosis was changed from one to six months, which is more consistent with the chronic nature of GAD. Despite these improvements, the vague somatic criteria remained, with clients requiring six out of 18 varied symptoms to meet diagnosis.

GAD in the DSM-IV and DSM-5

With the introduction of the DSM-IV in 1994, the diagnostic criteria for GAD became significantly streamlined and began to adequately reflect the independence of the disorder. Although excessive worry and anxiety was retained as the main feature of GAD, the term unrealistic was dropped and replaced with the notion that the worry is “difficult to control.” In addition, the minimum duration requirement of 6 months was retained. Taken together, these two criteria clearly reflect the fundamental nature of GAD as a chronic condition that distinguishes itself from nonclinical worry by a quantitative difference in worry frequency and intensity, rather than by a qualitative difference (as was suggested by the term unrealistic). The criterion of “excessive and uncontrollable” worry reflects the clinical reality that individuals with GAD generally worry about the same types of things as everyone else does. The difference is that they worry more about them and it is harder to stop worrying once they have started. Indeed, the criterion of “uncontrollable” worry and anxiety was incorporated to distinguish GAD from nonpathological worry (Barlow & Wincze, 1998), highlighting the fact that the difference between GAD and “non-GAD” worry is primarily a matter of degree, not content.

Another notable revision to the criteria in the DSM-IV was the exclusion of many somatic symptoms from the diagnosis. Specifically, all the autonomic hyperactivity symptoms were removed, as well as a number of items from the motor tension and vigilance/scanning categories. The exclusion of the hyperactivity symptoms was particularly beneficial because they are more likely to be seen among individuals with panic disorder than those with GAD. As such, prior to this revision, distinguishing between panic disorder and GAD was a significant challenge for clinicians. In the DSM-IV, there were only six somatic symptoms linked to a GAD diagnosis, and although all but one (i.e., muscle tension) can also be endorsed by clients suffering from other depressive or anxiety disorders, the six symptoms are reliably found among GAD clients. These include feelings of restlessness or being keyed up, being easily fatigued, experiencing concentration difficulties or mind going blank, muscle tension, and sleep difficulties (typically problems falling or staying asleep).

A final noteworthy change to the DSM-IV was the inclusion of “significant distress and impairment” to the GAD criteria. Earlier editions of the DSM described GAD as a disorder that engenders only mild social and occupational impairment. The prevailing perception of individuals with GAD was as the “worried well,” that is, as people who worry excessively yet are still able to accomplish most of their daily activities while maintaining acceptable levels of well-being and quality of life. Given that worry is a universal experience, it is not surprising that excessive worry might not be viewed as particularly disabling in one’s day-to-day life. Yet, both research and clinical experience stand in contradiction to this belief. In fact, a more apt description of people with GAD is as “the walking wounded.” Not only do they typically endure symptoms for many years without receiving treatment, but they may also experience significant social and economic disadvantages. For example, individuals with GAD are often divorced or not in a relationship, are more likely to have received disability payments at some time in their lives, and typically have very low annual incomes (e.g., Blazer, Hughes, George, Schwartz, & Boyer, 1991; Hunt, Issakidis, & Andrews, 2002). In addition, they frequently experience significant dissatisfaction with their professional and personal lives, as well as a diminished sense of well-being (Hoffman, Dukes, & Wittchen, 2008; Stein & Heimberg, 2004). As such, the DSM-IV revision to the impairment and distress criterion for GAD was more reflective of the actual presentation of the disorder.

It is striking that GAD was, and to some extent still is, viewed as a relatively mild disorder despite its association with poor quality of life, as well as social and occupational impairment. This inaccuracy is most likely due to the fact that the impairment associated with GAD is often compared to that seen in other anxiety disorders. For example, when discussing the interference in the daily lives of individuals with panic disorder, social anxiety disorder, or obsessive-compulsive disorder, the associated impairment is often quite obvious. Specifically, individuals with these disorders can engage in time-consuming and fear-driven behaviors as well as physical avoidance of specific places or events, rendering the disability apparent to both themselves and those around them. For example, an individual with obsessive-compulsive disorder characterized by contamination concerns might wash her hands so excessively that they bleed, or a person with panic disorder might become so fearful of having a panic attack that he rarely leaves the house. In contrast, the majority of individuals with GAD do not engage in behaviors that visibly demonstrate marked interference, nor do they necessarily appear particularly distressed or impaired by their symptoms. Rather, the lives of GAD clients are often fraught with subtle interference. For example, they might have difficulty concentrating on specific tasks at work because they are worrying about their retirement or fail to enjoy a weekend get-together with friends because they are concerned about the upcoming work week. Because these types of worries are commonplace among GAD clients, they have a considerable negative impact on productivity on a professional level (more on that later) and pleasure on a personal level (for example, clients are too preoccupied with potential problems to enjoy the pleasures of life). Further, due to the longstanding nature of the disorder, there is an additive effect to these interferences, and feelings of demoralization and exhaustion are often the end result of years of worrying. Consequently, although the impairments caused by GAD are sometimes less obvious, they are no less detrimental to one’s quality of life and are therefore of sig...