Generalized Anxiety Disorder: The CBT Approach

hello my name is Vince Greenwood I am the director of the Washington Center for cognitive therapy a mental health organization that specializes in the treatment of anxiety disorders in this video I am going to talk about generalized anxiety disorder also referred to as GA D generalized anxiety disorder is a diagnoseable condition characterized by excessive worry and a cluster of physical symptoms such as muscle tension restlessness fatigue irritability and sleep difficulties over the past few decades we have learned a good deal about generalized anxiety disorder and its treatment I am going to describe the components of generalized anxiety disorder the particular thoughts feelings and behaviors that make up GA D so that you have a clear more detailed understanding of GA D and show how that understanding has been utilized by cognitive behavioral practitioners to develop a highly effective research supported treatment for generalized anxiety disorder I am also going to provide some guidelines and how you can distinguish between a tendency to worry and full-blown GA D first I'd like to make the point that it is desirable and appropriate the generalized anxiety disorder is a diagnosable condition it deserves that designation because GA D is not just the tendency to worry or be keyed up we all have the tendency to worry from time to time to be keyed up and feel tense indeed those tendencies can be adaptive can help us prepare for emerging difficulties however worried intention can be excessive and therefore deserving of therapeutic attention research has shown that generalized anxiety disorder is a different animal altogether the person with GA D would describe himself as a constant warrior and those who knew him well would agree with that assessment his worries are persistent he feels stuck in his worried state he would also describe himself as stuck in a state of physical tension he might describe himself as uptight and tense all the time he is constantly vigilant and apprehensive as one GA D sufferer put it I feel like I'm always walking in a war zone we are all familiar with the notion of a cliffhanger as it applies to a novel or a movie the cliffhanger captures our attention it creates tension in a good way for the story however the world for the person with generalized anxiety disorder as reflected in their thoughts and worries is like living from one cliffhanger to the next but not in a good way they are constantly besieged by thoughts such as do I have enough money is there going to be a school shooting in my community do I need to develop more Skills to keep my job might I be developing heart disease did I say something stupid at the party last night is the economy going to collapse and on and on the world for the GED sufferer often shrinks down to this endless do loop of worries even if the person with generalized anxiety disorder a part of them anyway thinks their worry is unreasonable or excessive they still can't turn the worry off and that inability to turn the worry off is a central feature of GA D a major diagnostic criteria for GA D is that significant worry occurs almost every day for at least six months does worry tip from being helpful to not helpful the following questions can help flush out the tipping point for example when I notice I am wrapped up and worried and want to focus on something else am I able to switch the worry off are my worries extremely upsetting to me make it difficult to get things done do I worry so much that I am rarely able to relax do I notice that I worry about things that others worry about but in a more exaggerated manner do I worry much of the time without ever reaching a possible solution for a particular problem do I believe that if I don't worry a terrible event will be more likely to happen if your answer to a number of these questions is yes you might have generalized things our anxiety disorder and might want to examine the tendency to worry so much generalized anxiety disorder can be a torment for the person going through it ga d certainly undermines peace of mind it can get in a way of daily activities and responsibilities it can get so intense that the person has difficulty functioning over time it can contribute to physical health problems approximately 4% of the population struggles with generalized anxiety disorder so is that what is the particular nature of GA D this different animal early on when researchers were beginning to identify the particular details of GA D they found it desirable to think of GA D as having three basic components a thinking component which basically involves worrying a feeling component which involves feelings of anxiety and apprehension as well as those physical symptoms I mentioned earlier and a behavior component behavior that goes along with GA D includes avoiding situations that the person worries about were seeking reassurance about situations that worries about breaking generalized anxiety disorder down into component parts has a number of benefits many with GA D and those trying to help them find the condition to be diffused this pervasive tendency to worry in feel tense but by pinpointing its specific components we make the condition less mysterious and identify the particular components that then become targets for treatment and change we have also learned that these three components have a dynamic relationship with one another they reinforce one another and a kind of negative cycle the more one worries the more one feels tense which then leads to avoidance behavior or reassurance seeking behavior which often evokes more worry and so on the flip side of this cycle is that when we can effect a positive change in one component the thinking component worrying let's say that tends to generate positive change in the feeling and behavioral components of GA D so let's go through the three areas starting with a thinking or worrying component first let's define worry worry is usually defined as focusing our thoughts on some kind of threat that something undesirable is happening or could happen now this can be helpful at times but with GA d the worry is excessive and counterproductive to understand this 10 tendency we need to understand the particular quality of worry and those with GID when we zero in on those with excessive worry what do we see research has enabled us to pinpoint to fundamental ways of thinking which we characterize as distorted thinking two ways in which those with GA D interpret life events the first distortion involves overestimating the probability that something threatening or undesirable might happen for example a person with GA D hearing a report that the economy is not doing so well might jump to the conclusion that they are likely to lose their job the second key distortion involves overestimating the severity of the undesirable thing happening a tendency that has been labeled catastrophizing for example the person who worries about losing their job might view that possibility not just as something undesirable or quite stressful but is having very damaging ruinous unrecoverable impacts on their life or family they imagine the worst case scenario with chronic worriers it is not so much what they worry about they tend to worry about the same kinds of things as those that are not chronic worriers such as health concerns job or school performance finances trying to be a good friend or family member it's not what they worry about but how they worry specifically with these two distortions the over estimation of the probability and the over estimation of the severity of some undesirable event the threshold for worry is very low the person with GA D always feels on high alert the danger is lurking in addition we have also identified three beliefs associated with chronic worry these beliefs kind of basic rules of the road reflect the GA D sufferers attempt to ward off threats but these beliefs end up just reinforcing the worried State the first believe his perfectionism the belief that one cannot and should not make mistakes and that to make mistakes in judgment decision-making parenting work or whatever represents incompetence in managing life with this belief there is the constant pressure to always make the right judgment or display the perfect behavior the second belief relates to responsibility that it is irresponsible not to focus on negative possibilities thus words that pop up in one's mind should not be ignored and that worrying means you are being responsible whereas not worrying is to be irresponsible the third key belief that we have identified we label controllability the belief that worry is a way of gaining control and preventing negative outcomes from coming true this is reflected in a thoughts such as I am glad I worried about my daughter because she made it safely home from a trip these three beliefs maintain the worry and anxiety and help explain why chronic worriers have such difficulty switching off their worry and anxiety even though there is a part of them that wants to switch it off there is also a part of them that feels that switching it off would be irresponsible and might even increase the possibility of some unwanted outcome the good news is our detailed understanding of these thinking errors and beliefs that lead to chronic worry have enabled us to design targeted treatment strategies to counteract and help those for whom worry has become to seem so intractable the second component of GA D is the physical component which refers to the physical sensations or symptoms such as restlessness difficulty relaxing trouble falling asleep or staying asleep usually due to the mind racing also feeling easily tired headaches gastrointestinal difficulties and feeling irritable and on edge these physical sensations are a result of our brains sending a message to our autonomic nervous system the message sent is there's some kind of threat and we need greater energy the energy that goes along with our fight-or-flight system we need that energy to deal with the threat now let me give just a brief description of how our nervous system works the autonomic nervous system has two branches called a sympathetic branch and the parasympathetic branch the sympathetic branch revs up our energy to deal with the threat the parasympathetic branch puts on the brakes to this energy arousal when it's no longer needed the parasympathetic branch helps us to regain our emotional balance and restores our body to a normal resting state however the research on gid suggests that there are low levels of parasympathetic control which means that those with GA D don't put on the brakes as frequently or effectively as they should the result is our bodies get stuck in a state of higher arousal when they no longer need to be in a state of high arousal kind of like they're stuck in third gear in situations in which they only need to be in second gear which explains the classical physical symptoms of GA D such as muscle tension sleep difficulty irritability and difficulty relaxing the third component of g ID is behavior we want to highlight three kinds of behavior in relation to GA d first there is the behavior that is the direct result of anxiety such as difficulty concentrating and restlessness we want to target this behavior because it compromises one's ability to solve problems avoidance is another important behavioral component of GA D when we feel threatened by something we tend to avoid it that's not always a bad thing but if we are overestimating the threat then avoiding it just reinforces the notion that the threat is serious by avoiding we miss the opportunity to see that perhaps the threat is not as bad as we predicted or that we can cope with it the threat even if it is somewhat difficult another meaningful behavior involves what we call over cautiousness or reassurance seeking behavior examples might include calling frequently to make sure your family members are safe or being overprotective with your children such behavior may provide reassurance briefly but ends up contributing to your chronic worry now that you have a more detailed understanding of the components of GA D let's turn to the treatment approach the cognitive behavioral treatment of GA D is a scientific approach in which you develop skills to think behave and react physically in new ways to overcome your chronic worry and anxiety with CBT you will learn how to alter the negative predictions which lead you to feel unsafe and out of control learn how to alter them by thinking more accurately about the real possibilities of something bad happening you will learn how to think less catastrophic ly and to rehearse coping with real-life difficulties and CBT you will learn how to shift your body from its tense state caused by a constant over arousal of your nervous system to a more relaxed state thereby interrupting the vicious cycle Woori leading to physical tension leading to more worry and so on you will learn how to change your reassurance seeking behavior so you learned that the dangers you predict either do not happen or you realize you can cope with them you will learn how to take on situations you may have avoided because of your negative predictions and you will learn effective problem-solving strategies to deal with the legitimate stressful events in your life I will describe some of these skill sets in a few minutes but first let me outline the first stage of treatment which we call the self-awareness or self monitoring stage this is where we ask the client to monitor and record their anxiety and worry states so they can learn the when where and under what circumstances they have anxiety we also ask them to pinpoint and record the particular thoughts that make up their worried state and the particular physical symptoms they are experiencing when anxious and the behaviors triggered by their anxiety including behaviors they display to try to get reassurance this self-monitoring step has a number of benefits most critically it identifies the particular thinking feeling and behavioral components of anxiety that we want to target for treatment it also facilitates becoming more of an observer of one's anxiety and worry rather than just being a victim of it by pinpointing the conditions under which one gets anxious and the different components of the anxiety this manner this monitoring counteracts one of the core vulnerabilities of someone who has gid namely that they feel that their anxiety and worry is unpredictable and uncontrollable becoming more of an objective observer of their anxiety rather than just being swept up in it gives hope that this condition can perhaps be controlled and by keeping a record of the frequency and intensity of the anxiety episodes we have a record from which to measure progress once we start the treatment strategies after a few sessions developing this self monitoring skill the component of gid that we often turn our attention to first is the physical symptoms the physical tension that is one of the hallmarks of chronic worry this is an important target for change because the physical symptoms are painful often the reason someone seeks out treatment and because this state of chronic over arousal of the nervous system leads to a greater susceptibility to worry it would certainly be desirable to have a tool to reduce this physical tension well there is such a tool called progressive muscle relaxation where the person develops the skill to shift their body from a tense state to a noticeably more relaxed state a tool to bolster the parasympathetic branch of their nervous system progressive muscle relaxation is much more than telling a person to relax it is a key anxiety management skill which requires a good deal of practice another reason why we introduce it early in treatment however once learned it can be quite helpful here's how it works first we ask you to focus on a particular muscle group in your body my muscle group we simply mean the muscles in a particular part of your part of your body such as the muscles in your shoulder area muscles in your upper arms or lower arms muscles surrounding your abdomen so on we start with one muscle group let's say the muscles in your shoulder area and ask you to tense up and those muscles to scrunch up your shoulders and make them tense and tight and then to hold that tension for about 10 seconds in this step you try to create as much tension as you can and to focus on that tension then we give a signal usually saying the word relaxed whereby we asked you to let go of the tension just let the muscles go limp and relaxed we ask you to keep your focus on that same muscle group and notice the contrast between the tension when your muscles were scrunched up and the release of tension the relaxation we ask you to keep that focus on the relaxation for about 20 seconds during which time we ask you to say a word to yourselves typically the word relaxed every time you exhale now what's behind this technique how is it effective by creating tension and then releasing it we've learned that this facilitates the relaxation response it gives the relaxation response some momentum kind of like a pendulum that's set up high and therefore swings higher to the other side the relaxation response is stronger after the release of tension by focusing attention on the muscle groups you learn that tension doesn't have to be your default state but something you can begin to exert some control over also by focusing on the body and the here-and-now you are weakening the association between tension and worry if you do notice where he's popping up during the exercise we can encourage you to do a mindfulness exercise such as picturing the worries as clouds passing by in the sky or is background noise outside your apartment that you don't have to pay it - when we first teach progressive muscle relaxation in the office we move from one muscle group to the next initially we go through 16 different muscle groups in the body we then ask the client to practice this progressive muscle relaxants relaxation exercise at home without distractions this is time consuming initially it can take about 30 minutes to go through all the muscle groups however we emphasize that it is a skill and like any skill requires time and practice this is the training phase of progressive muscle relaxation we then move to the application phase which initially involves reducing the number of muscle groups from 16-day we don't eliminate any muscle groups we just combine them so the client tenses and relaxes more muscle groups together covering a larger portion of the body by reducing the number of muscle groups to eight we shorten the procedure the client then practices this until he develops some mastery with it then we shift the number of muscle groups to four then two and finally a one-step entire muscle relaxation shift we ask the client to practice this one step procedure with distractions thus they are then able to carry this skill of shifting from tension to relaxation into real-life situations progressive muscle relaxation is not a magical cure-all for all the components of GA d but it is a concrete tool that provides relief breaks up the vicious cycle of tension leading to worry and gives the client hope that they can have control over what had been seen as an uncontrollable condition now let's turn our attention to the thinking component the intense worry we described earlier I here we're not talking about constructive Ori which can help us prepare for a problem but worry that is excessive worry we can't turn off fortunately there are many techniques we can bring to bear to disrupt this tendency to worry a colleague Robert Lee he in an excellent self-help book called the worry cure has outlined many of these strategies most of them are cognitive techniques aimed to identify question and dispute the thoughts that make up the worry remember research has identified that two of the frequent characteristics of worry with GA D sufferers are the tendency to overestimate the likelihood of a negative event and the tendency to imagine the worst-case scenario of a negative event so how does this disputing work particularly to challenge these two key distortions in GA D the first step is to identify the specifics that make up the worry people with GA D typically feel lost in a sea of worry unable to view their anxiety and worry objectively however in that self-monitoring phase of treatment clients realize that their worries are really a list of specific thoughts almost always predictions about something bad that might happen in the future by identifying the worries as specific predictions the client begins to feel not so overwhelmed by their worries and feel that they are in a better position to question those predictions the next step is to do just that to evaluate the real odds of something undesirable happening we pose questions such as what do you think the real odds are of the negative prediction coming true how often have you worried about a particular negative outcome for example getting fired or that a loved one will get in an automobile accident how many times have you worried about those things and how many times have they actually come true are there facts or data you could seek out they might help you make a more accurate prediction such as the statistics of the likelihood of someone getting into a serious automobile accident thus the client learns how to pose questions that help determine the real odds the real likelihood of some negative event happening questions that lead to answers that have integrity meaning they are based on evidence the next step that flows from this questioning is to put into words or pictures the more realistic scenario to picture your spouse arriving home safely in the car or perhaps picture a conversation with your supervisor where the supervisor might not be totally happy with your work but the conversation doesn't result in you getting fired now how do we deal with the second distortion and unproductive worry the tendency to imagine the worst case scenario for example imagining that you're going to be fired effort after turning in a less-than-perfect report imagine that you're going into bankruptcy after incurring a little bit of debt well first we always want to question the likelihood of these particular negative predictions but then we go ahead and encourage the person to picture their worst case scenario and ask them to rate the severity of it in the midst of worry they have almost always considered the event as awful god-awful catastrophic something they just couldn't bear but if asked to actually rate it we usually suggest a scale of zero to a hundred or a hundred represents the most awful thing they imagine they often recognize that the event they are worried about is not the most awful event the event is undesirable perhaps very undesirable but there's a recognition that it is perhaps not absolutely god-awful the next question is to ask them to picture the undesirable event and then imagine how they might cope with it how life might go on even if the undesirable event happens most people with GID don't take this step and therefore in their minds they're always stuck in this kind of cliffhanger image the bad thing happening or about to happen but not what could happen next by picturing how they might cope they realize they are not stuck in a cliffhanger image and that there might be things they could do to deal with the unfortunate event D catastrophizing is going from the thought oh my god what if such-and-such happens to the thought even if something unfortunate happens I can imagine coping with it and that it's not absolutely insufferable now let's turn to the behavioral component of GID one of the key behavioral components of GA D that we want to target for change is what we call reassurance or safety seeking behavior this is behavior design to try to reduce the possibility of some negative outcome or to try to reduce the worry about that outcome examples might be constantly checking in with your family to make sure they are safe or always staying late at work to minimize the chance you won't get your work done on time this behavior may provide someone with reassurance briefly but when relied upon ends up reinforcing the worry because the person doesn't give himself a chance to see that the negative thing they are worried about doesn't happen or if it does can be made instead of challenging their thinking involved in their worry they engage in behavior that gives in to the excessive worry thus we try to reduce this reassurance seeking anxiety driven behavior and replace it with non anxious behavior such as calling your family less frequently about their safety not feeling compelled to stay at work late every night to always get your work done on time the goal here is to build up the behavior that goes along with tolerating imperfection letting go of attempts to control everything letting go of this sense of responsibility for unlikely events and recognizing that making mistakes is part of being human when someone pushes back against their reassurance seeking behavior that can cause an increase in anxiety in the short run therefore we usually focus on behavior change after the person has learned the coping skills of relaxation and thinking more realistically they can then bring these skills to bear on building up new behavior new behavior that undermines their general tendency to worry and be tense and constantly seek reassurance likewise if someone with GID has been avoiding legitimate problems such as seeing a doctor when appropriate or developing a realistic budget we encourage taking on these situations especially since they now have new coping skills pushing back on the tendencies to seek reassurance and a tendency to avoid situations that need to be tackled will help cement the tendency to worry less and help solve problems more effectively this is the ultimate goal of treatment I hope this has given you a thumbnail sketch of how CBT can help those generalized anxiety disorder by addressing the components of worried physical tension and self-defeating self-defeating behavior with specific techniques I describe some of the techniques but there are many other techniques that can be helpful if you want to learn about these techniques or about the treatment of other anxiety difficulties please don't hesitate to visit our website I want to conclude by emphasizing the GA D is a condition worthy of treatment and fortunately there is a research tested effective treatment program to help those who suffer from chronic worry thank you you

Channel: The Washington Center for Cognitive Therapy

Views: 329,405

Rating: 4.9039674 out of 5

Keywords: CBT and GAD, What is GAD?, Excessive Worry, GAD: What it is and how to treat it, generalized anxiety disorder, GAD, Treatment of GAD, How To Treat, Tutorial

Id: OwSz0uAioII

Length: 36min 24sec (2184 seconds)

Published: Tue Aug 14 2018