Treating Generalized Anxiety Disorder: Evidence-Based Strategies, Tools, and Techniques

224 Pages·2004·1.08 MB·English

by  Jayne L. Rygh

Treating Generalized Anxiety Disorder

Treating
Generalized
Anxiety
Disorder
EVIDENCE-BASED
STRATEGIES, TOOLS,
AND TECHNIQUES
JAYNE L. RYGH and WILLIAM C. SANDERSON
THE GUILFORD PRESS
New York London
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LibraryofCongressCataloging-in-PublicationData
Rygh,JayneL.
Treatinggeneralizedanxietydisorder:evidence-basedstrategies,tools,andtechniques/JayneL.Rygh,
WilliamC.Sanderson.
p.cm.
Includesbibliographicalreferencesandindex.
ISBN1-59385-039-5(pbk.:alk.paper)
1. Anxiety—Handbooks,manuals,etc. 2. Cognitivetherapy—Handbooks,manuals,
etc. I. Sanderson,WilliamC. II. Title.
RC531.R932004
616.85(cid:1)220651—dc22
2004009229
AbouttheAuthors AbouttheAuthors
About the Authors
JayneL.Rygh,PhD,isaseniorpsychologistattheCognitiveTherapyCenterofNewYork,where
sheisbothapsychotherapistandasupervisor.Usingcognitive-behavioralandschematherapies,
Dr.Ryghtreatsclientssufferingprimarilyfromanxiety,depressive,andpersonalitydisorders.In
addition, she has served as an independent evaluator and research psychotherapist in numerous
National Institute of Mental Health grants on the treatment of anxiety disorders.
William C. Sanderson, PhD, is Professor of Psychology at Hofstra University. He has served on
numerous national committees, including the American Psychiatric Association’s DSM-IV Anxi-
ety Disorders Workgroup, and was recently Chair of the Committee on Science and Practice (a
taskforceaimedatidentifyingandpromotingthepracticeofempiricallysupportedpsychological
interventions) of the American Psychological Association’s Division of Clinical Psychology. Dr.
Sandersonhaspublishedsixbooksandmorethan85articlesandchapters,primarilyintheareas
of anxiety, depression, personality disorders, and cognitive-behavioral therapy.
v

Preface Preface
Preface
Generalized anxiety disorder (GAD) is a prevalent and disabling clinical syndrome that requires
treatment. Not only does it commonly occur on its own, but it is perhaps the most frequent
comorbiddiagnosisamongpatientswithdepressivedisordersandotheranxietydisordersaswell.
Thus clinicians are very likely to see many patients with GAD.
Only one psychosocial treatment—cognitive-behavioral therapy (CBT)—has a substantial
body of empirical research supporting its efficacywith GAD. As a result, this treatmentis an es-
sential “tool” for any clinician treating adult outpatients.
This book was written to provide clinicians with a wide variety of empirically supported as-
sessment and psychosocial treatment options. Within this framework, direction is given on how
information from the assessment can be used to select and weave various treatment techniques
into a comprehensive treatment plan for an individual patient. Each strategy is presented in ex-
tensivedetail,sothatthereadercanimplementthesetechniquesonthebasisofthedescriptions
provided.Detailedinformationisprovidedabouttreatmentselection,rationale,andimplementa-
tion. As much as possible, step-by-step instructions are provided. In order to bring the
descriptions to life, case illustrations are included.
AlthoughtheeffectivenessofthetraditionalCBTtechniquesoutlinedinthisbookiswelles-
tablished,thesetechniquesarenotwithoutlimitations.Asisthecasewithmanyotherempirically
supportedpsychologicalandpharmacologicaltreatments,manypatientsdonotbenefit.Recently
there has been a proliferation of research on other techniques applied to GAD in efforts to im-
provetreatmentefficacy.Since theseadditional techniquesare in theprocess of being subjected
towell-controlledtreatmentoutcomeresearch,theirefficacyhasnotyetbeenestablished.Butul-
timately they may prove useful with clients who do not respond well to traditional CBT alone.
Though continued efforts need to be focused on improving this treatment, CBT is presently the
best available psychotherapeutic intervention for GAD.
JAYNE L. RYGH and WILLIAM C. SANDERSON
vii

Contents Contents
Contents
List of Tables, Figures, and Handouts xi
CHAPTERONE. Generalized Anxiety Disorder: Diagnosis, Theories, and Treatment 1
Diagnostic Criteria 1
Differential Diagnosis 1
Coexisting Conditions 2
Prevalence and Life Course 3
Genetic Factors 3
Environmental Factors 4
Costs Associated with GAD 5
Treatment Outcome Studies 5
Behavioral and Cognitive Theories of Anxiety Disorders,
and Related Treatment Techniques 11
Theories of GAD 14
Conclusions 17
CHAPTERTWO. A General Description of Treatment 18
Overview of the Model Used in Treatment 18
Techniques That Target the Cognitive Component 21
Techniques That Target the Physiological Component 24
Techniques That Target the Behavioral Component 24
Techniques That Target Associated Problems 25
Empirical Support for Treatment Techniques 25
Basics of Implementing CBT Techniques 25
CHAPTERTHREE. Assessment and Treatment Planning 28
Diagnostic Clinical Interviews 28
Self-Report Measures for Diagnosis and Severity 36
ix
x Contents
Assessing Idiosyncratic Aspects of GAD 36
Assessing Problematic Patterns in Past and Current Relationships 47
Assessing Pleasurable Activity 51
Tailoring Treatment to Fit the Individual Client 51
CHAPTERFOUR. Socialization to Treatment 58
General Information about Anxiety and Worry 58
Presentation of the Model Used in Treatment 65
Presentation of the Treatment Rationale and Techniques 69
Problematic Client Responses in the Socialization to Treatment 72
CHAPTERFIVE. Treating the Cognitive Component 77
Cognitive Restructuring 77
Positive Imagery 99
Worry Exposure 100
Improving Problem Orientation 107
Cost–Benefit Analysis of Coping Responses 108
Scheduled Worry Time 108
Worry-Free Zones 111
Problematic Client Responses to Cognitive Techniques 111
CHAPTERSIX. Treating the Physiological Component 112
Progressive Muscular Relaxation (PMR) 113
Diaphragmatic Breathing 122
Self-Control Desensitization 124
Applied Relaxation 129
Problematic Client Responses to Relaxation Techniques 130
CHAPTERSEVEN. Treating the Behavioral Component 132
Response Prevention 133
In Vivo Exposure 141
Pleasurable Activity Scheduling 145
CHAPTEREIGHT. Supplementary Treatment Techniques 150
Mindfulness 151
Emotional Processing and Regulation Training 160
Interpersonal Effectiveness 171
Time Management 188
CHAPTERNINE. Ending Treatment 190
Self-Directed Continuation of Treatment 191
The Importance of Cognitive-Behavioral Therapy for GAD in the Evolving
Health Care Environment 194
References 197
Index 205