Treating Clients With Generalized Anxiety Disorder
In Treating Clients With Generalized Anxiety Disorder, Dr. Michelle G. Craske demonstrates her cognitive–behavioral approach to working with clients with this disorder. Generalized anxiety disorder involves consistent feelings of anxiety, excessive worry, and tension. Typically there is little or no provocation for the client's worry, and there may also be physical symptoms such as muscle aches and fatigue. Cognitive–behavioral therapy focuses on thoughts and actions that might contribute to the anxiety and on helping clients see any negative bias they may have in interpreting information.
In this session, Dr. Craske works with a 56-year-old woman who feels overwhelmed by her workload and worries incessantly about her son. Dr. Craske guides the client through anxiety-producing imagery, introduces strategies for handling her anxiety, and helps the client begin to interpret life events in a more realistic way.
Dr. Craske uses a cognitive–behavioral therapy approach that draws upon the latest developments in cognitive science and learning theory. She uses a biopsychosocial model for conceptualizing anxiety disorders, in which the broad-based vulnerability of neuroticism, or proneness to negative affect, along with its genetic and environmental contributions, is recognized as a primary factor that increases the risk for all forms of anxiety as well as depression.
When such negative affectivity is combined with poor emotional regulation strategies, or maladaptive appraisal mechanisms and avoidant coping, then the proneness to anxiety is enhanced. Manifest anxiety is believed to be characterized as well as maintained by processes that are common to all anxiety disorders, including hypervigilance to sources of threat, or selectivity of attention to threat-relevant stimuli and an appraisal bias in which the risk and valence of potentially threat-relevant stimuli are elevated. These judgment biases of risk and valence in turn contribute to the tendency to selectively attend to threat-relevant stimuli, even at a preconscious level, and thereby contribute to ongoing anxiety.
Another anxious process is avoidant behavior, including compulsive rituals, safety-seeking, reassurance-seeking, distraction, overt escape from or avoidance of specific stimuli. Such overt and covert avoidance behavior is presumed to prevent corrective learning so that appraisal biases and selective attention to sources of threat are maintained, and thereby anxiety is maintained in the long-term.
A third anxious process involves a state of physiological preparation for threat, which in turn supports and perpetuates hypervigilance to threat and avoidant coping. The particular stimuli that become most fear-provoking to an individual are presumed to derive from personal history of experiences, including direct traumatic experiences, vicarious learning of observing others experiencing fear or being traumatized, and informational transmission regarding the threat value of specific stimuli, with each experience building upon and being buffered or potentiated by the entire history of experiences and constitutional variables.
Cognitive–behavioral therapy assumes that treatment is best targeted at the processes which maintain anxiety, those being the hypervigilance to threat, avoidant behaviors, and physiological preparedness. Dr. Craske's particular approach is one that emphasizes both cognitive restructuring designed specifically to offset the anticipatory anxiety that contributes to avoidant behaviors, as well as methods for optimizing learning during the exposure to feared stimuli. Occasionally, somatic types of interventions may be incorporated, such as relaxation or slow breathing, and although they may have a physiologically calming effect, sometimes they are used to offset appraisal biases and avoidant behavior.
Typically, the treatment begins with education about the nature of fear, panic, and anxiety; the causes of panic and anxiety; and the way in which panic and anxiety are perpetuated by feedback loops among physical, cognitive, and behavioral response systems. In addition, specific descriptions of the psychophysiology of the fight–flight response are provided, as well as an explanation of the adaptive value of the various physiological changes that occur during panic and anxiety. The purpose of this education is to correct the common myths and misconceptions (i.e., beliefs about going crazy, dying, or losing control) that contribute to panic and anxiety, and to enhance a personal scientist model for understanding emotional reactions.
Along with psychoeducation is the introduction of self-monitoring as a way of enhancing objective self-awareness. Clients are educated in ways of recording triggers, the three response components (thoughts, behaviors, and physical feelings), and various parameters such as the intensity of anxiety experienced.
Breathing skills may be incorporated into the treatment, beginning with education about respiratory physiology and the harmless nature of hyperventilation. Breathing skills are introduced as a partial antidote to overbreathing, although the primary purpose of the breathing skill is to encourage continued approach to anxiety or anxiety-provoking situations. Thus, the focus of breathing skills is not on symptom reduction or immediate fear reduction.
Cognitive restructuring assumes that emotions are based on cognitive processes that can be corrected or manipulated via conscious reasoning. Cognitive skills are introduced at the same time as breathing skills, both intended as means of encouraging approach to anxiety or anxiety-provoking stimuli.
Beck's approach to cognitive therapy forms the basis of Dr. Craske's approach. Beck's approach follows a course of collaborative empiricism, in which client and therapist work together to identify and label errors in thinking, evaluate the evidence, and generate alternative, more realistic hypotheses. Typically, cognitive therapy begins with discussion of the role of thoughts in generating emotions, to provide a treatment rationale. Next, thoughts are recognized as hypotheses rather than fact, and therefore open to questioning and challenge. Detailed self-monitoring of emotions and associated cognitions is instituted to identify specific beliefs, appraisals, and assumptions.
Once relevant cognitions are identified, they are categorized into types of typical errors that occur during heightened emotion, such as overestimations of risk of negative events or catastrophizing of meaning of events. The process of categorization, or labeling of thoughts, is consistent with a personal scientist model, and facilitates an objective perspective by which the validity of the thoughts can be evaluated. Thus, in labeling the type of cognitive distortion, the client is encouraged to use an empirical approach to examine the validity of his or her thoughts by considering all of the available evidence.
Therapists use Socratic questioning to help clients make guided discoveries and question their anxious thoughts. Next, alternative hypotheses are generated that are more evidence-based. In addition to surface level appraisals (such as "that person is frowning at me because I look foolish"), core level beliefs or schemata (such as "I am not strong enough to withstand further distress" or "I am unlikeable") are questioned in the same way. Cognitive restructuring is not intended as a direct means of minimizing fear, anxiety, or unpleasant symptoms. Instead, cognitive restructuring is intended to correct distorted thinking; eventually fear and anxiety will subside, but their diminution is not the first goal of cognitive therapy.
The crux of the treatment is exposure therapy, which entails systematic and repeated confrontation with phobic stimuli in the absence of aversive outcomes. The phobic stimuli encompass external (i.e., agoraphobic situations) as well as interoceptive (i.e., bodily sensations) cues.
There are several variations in the way exposure is conducted. They include the modality through which stimuli are presented: imaginal, virtual reality, and in vivo (in real life). Another variation is the intensity of exposure, ranging from graded exposure, progressing from the least to the most feared exposure task, to intense flooding therapy, or exposure to intensely feared stimuli for protracted lengths of time. For the most part, a graduated approach is recommended. A third variation is the rate at which exposure is conducted, varying from a massed schedule (e.g., once every day for several weeks) to a spaced schedule (e.g., once every week for several months). In general, more benefit is obtained from regular exposures.
Parameters used to determine the length of each exposure practice have varied over the years. Due to recent advances in learning theory and basic research, we have moved away from the model of "stay in the situation until fear has declined" to "stay in the situation until you have learned what you need to learn, and sometimes that means to learn that you can tolerate fear." Thus, we no longer look for fear reduction within a given exposure trial as a sign of success but instead look for eventual reductions in maximum fear levels across days of exposure practice.
Exposure is conducted in relation to internal feared cues (such as memories of trauma, catastrophic images, or feared bodily sensations) and to external feared cues (or situations in which anxiety is anticipated). Essential to effective exposure is the elimination of safety signals.
Multiple mechanisms are presumed to be accountable for therapeutic change through exposure therapy. Knowledge of these mechanisms facilitates the design of treatment in the most effective way possible.
The term habituation refers simply to reduction in response strength with repeated stimulus presentations. Thus, fear declines as feared objects are faced over and over again. Excessively high levels of arousal are likely to impede habituation. In addition, habituation is impeded by lengthy intervals between each occasion of exposure, which is another reason for regular exposure practice. However, habituation is unlikely to account for long-term fear reduction because it is a nonlearning process and habituated responses will dishabituate over time.
Extinction refers to decrements in responding through repetition of unreinforced responding: repeated encounters with feared stimuli (conditioned stimulus, CS) without aversive consequences (unconditioned stimulus, US). Thus, the person who is fearful of height learns by repeated exposures that he or she does not fall. Extinction accounts are supported by the finding that a single lengthy exposure session is generally more effective than a series of short exposures for the same total duration, as lengthy exposure provides sufficient time to learn that aversive outcomes do not occur.
Wolpe (1958) attributed extinction to counterconditioning or reciprocal inhibition. Specifically, when a response antagonistic to anxiety can be made to occur in the presence of anxiety provoking stimuli, and results in a complete or partial suppression of the anxiety response, then the bond between the stimulus and the anxiety response is weakened. However, his model was criticized because exposure can proceed effectively without including specific antagonists to anxiety.
Recent conditioning models maintain that extinction involves learning of new, inhibitory CS–US associations as opposed to unlearning of original CS–US associations. Thus, Bouton and colleagues (see Bouton, 1993) propose that the original excitatory meaning of the CS is not erased during extinction but rather an additional inhibitory meaning is learned. The resulting dual meaning of the CS creates an ambiguity which is resolved only by the current context of the CS. Bouton uses the analogy of an ambiguous word. That is, reaction to the word "fire" depends largely on the context in which it occurs; "fire" may elicit a panic reaction in a crowded theater and elicit very little reaction in a carnival shooting gallery. Thus, the context determines which meaning is expressed at any given time. In terms of anxiety treatments, bodily sensations may mean "sudden death" when experienced in a context that reminds the person of intense panic attacks before treatment, whereas the same sensations may mean "unpleasant but harmless" when experienced in a context that reminds a person of their success with treatment.
Self-Efficacy and Control
According to self-efficacy theory, therapeutic gains are dependent on the degree to which self-efficacy, or confidence to perform a certain task, is generated (Bandura, 1977). Self-efficacy is theoretically distinct from outcome expectancies, which refer to the perceived likelihood and valence of negative events. Efficacy expectations are claimed to influence the choice of activities and settings, and determine the degree of effort expended and persistence in the face of obstacles or aversive experiences. In other words, self-efficacy is believed to influence coping in threatening situations. Self-efficacy judgments are posited to derive from four main sources of information: performance accomplishment, verbal persuasion, vicarious experience, and physiological arousal. The strongest source is the first, as it is through performance accomplishment that one obtains most evidence for personal achievement and skills.
Related to self-efficacy is the notion that fear declines as perceived control increases (Barlow, 1988). In particular, a reversal of the fear action tendency, or reduction of escape urges or behaviors, leads to a sense that events or emotions are no longer proceeding uncontrollably, which in turn lessens fear and anxiety. This process can be set in motion by preventing the fear action tendency or by introducing specific competing tendencies, such as those characteristic of positively valent emotional states (e.g., humor).
The concept of emotional processing, first introduced by Rachman (1981) and extended by Foa and Kozak (1986), combines the concepts of habituation and cognitive modification. Foa and Kozak hypothesized two necessary conditions for fear reduction: full activation of fear, and incorporation of new material that is incompatible with fear memories so that new memories are formed.
The most effective method for activating fear is direct exposure to feared stimuli. With repeated exposure, the model states that incompatible information is derived from short-term physiological habituation that dissociates stimulus and response (i.e., recognition that the stimulus can occur in the absence of arousal). Between-session habituation is attributed to changes in the meaning of the stimulus and response (i.e., risk of harm is lowered and affective valence becomes less negative). That is, outcome expectancies are altered. Thus, there are three indicators of emotional processing: evidence of initial physiological arousal and self-report distress (i.e., fear activation), reactions gradually reduce during exposure (i.e., within-session habituation), and initial reactions to the stimulus reduce across exposures (i.e., between-session habituation).
Violation of Expectancies and Fear Toleration
However, given the recent advances in research, showing that neither physiological habituation nor the amount of fear reduction within an exposure trial is predictive of overall outcome (see Craske & Mystkowski, 2006), and given that self-efficacy through performance accomplishment is predictive of overall phobia reductions (e.g., Williams, 1992), and that toleration of fear and anxiety may be a more critical learning experience than the elimination of fear and anxiety (see Eifert & Forsyth, 2005), the focus now is upon staying in the phobic situation until the specified time at which clients learn that what they are most worried about never or rarely happens, or that they can cope with the phobic stimulus and tolerate the anxiety.
Thus, the length of a given exposure trial is not based on fear reduction but based on the conditions necessary for new learning, which eventually leads fear and anxiety to subside across trials of exposure. Essentially, the level of fear or fear reduction within a given trial of exposure is no longer considered an index of learning, but rather a reflection of performance; learning is best measured by the level of anxiety that is experienced the next time the phobic situation is encountered or at some later time.
This is also the reason why it is essential to replace escape and avoidance behavior, including safety behaviors and reliance on safety signals, with toleration of fear and anxiety.
Michelle G. Craske received her PhD from the University of British Columbia in 1985. She has published over 200 articles and chapters in the area of fear and anxiety disorders. She has written books on the topics of the etiology and treatment of anxiety disorders, gender differences in anxiety, and translation from the basic science of fear learning to the clinical application of understanding and treating phobias, in addition to several self-help books and therapist guides.
In addition, she has been the recipient of continuous National Institute of Mental Health funding since 1993 for research projects pertaining to risk factors for anxiety disorders and depression among children and adolescents, the cognitive and physiological aspects of anxiety and panic attacks, and the development and dissemination of treatments for anxiety and related disorders.
She was associate editor for the Journal of Abnormal Psychology, and is presently associate editor for Behaviour Research and Therapy as well as a scientific board member for the Anxiety Disorders Association of America. She was a member of the DSM-IV Anxiety Disorders Work Group and is now a member of the DSM-V Anxiety Disorders Work Group.
Dr. Craske has given invited keynote addresses at many international conferences and frequently is invited to present training workshops on the most recent advances in the cognitive–behavioral treatment for anxiety disorders. She is currently a professor in the Department of Psychology and Department of Psychiatry and Biobehavioral Sciences, UCLA, and director of the UCLA Anxiety Disorders Behavioral Research program.
- Barlow, D. H., & Craske, M. G. (2006). Mastery of your panic and anxiety: Client workbook (4th ed.). New York: Oxford University Press.
- Craske, M. G. (1999). Anxiety disorders: Psychological approaches to theory and treatment. Denver, CO: Westview Press/Basic Books.
- Craske, M. G., Antony, M., & Barlow, D. H. (2006). Mastery of your fears and phobias: Therapist guide (2nd ed.). New York: Oxford University Press.
- Craske., M. G., & Barlow, D. H. (2005). Mastery of your anxiety and worry: Client workbook (2nd ed.). New York: Oxford University Press.
- Craske, M. G., & Barlow, D. H. (2006). Mastery of your panic and anxiety: Therapist guide (3rd ed.). New York: Oxford University Press.
- Craske, M. G., & Barlow, D. H. (in press). Panic disorder and agoraphobia. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders (4th ed.). New York: Guilford Press.
- Craske, M. G., & Mystkowski, J. (2006). Exposure therapy and extinction: Clinical studies. In M. G. Craske, D. Hermans, & D. Vansteenwegen (Eds.), Fear and learning: Basic science to clinical application. Washington, DC: American Psychological Association.
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