Cognitive-behavioral Treatments In GAD

Excessive anxiety and worry are two of the core components of generalized anxiety disorder (GAD). There are no differences in the content of the concerns of “normal” people and those with GAD. However, Dugas and Ladouceur (1997) have pointed out that the latter are concerned with more and less important situations.

People with GAD worry about unlikely situations and also maintain the state of worry over time, as they jump from one to another. People with GAD seeking treatment have a greater anxiety trait, less perceived attentional control, and a greater need to control thoughts.

Generic or classic cognitive behavioral therapy

Cognitive behavioral therapy (CBT) combines Beck’s cognitive therapy with applied relaxation training. Data of clinical significance confirm that applied relaxation and CBT modalities are relatively effective. Classic cognitive therapy includes the following components:

• Training to become aware of and react to internal stimuli and external events that produce anxiety.
• Stimulus control strategy to postpone worries to a specific time and place of the day.
• Relaxation. Various techniques have been used: progressive relaxation, slow and regular breathing, and meditation techniques.
• Cognitive restructuring of the content and usefulness of concerns. The thoughts, images, and beliefs associated with the anxious response are identified. The Socratic method is used to examine the data for and against, generate alternative interpretations, and de-catastrophize.
• Graduated exposure, through imagination and live, to anxiety-provoking internal stimuli and situations. The purpose of learning to handle this by applying the strategies learned.

Borkovec’s cognitive-behavioral therapy

The CBT of the Borkovec group includes all the elements mentioned in generic or classic cognitive behavioral therapy, plus the following two that are part of acceptance and commitment therapy:

• Minimize negative expectations and predictions: The idea is to live longer in the present without continually correcting erroneous expectations about future events.
• Living according to one’s own values: the patient’s values ​​are identified to carry out activities in the present moment that allow them to achieve them.

Barlow’s cognitive behavioral therapy

Brown, O’Leary and Barlow (1993, 2001) have developed a treatment for GAD that includes conceptualization of the problem and justification of the treatment, relaxation training, cognitive restructuring, exposure to the fears that underlie worry, prevention of behaviors security and time organization. We analyze them in more detail below:

• Relaxation training: it is based on the progressive relaxation training of Bernstein and Borkovec. Any other relaxation technique that has been effective for the patient can be used.
• Cognitive restructuring: follow Beck’s principles. The concept of negative thoughts, the influence of situations on them, the impact of interpretations and predictions on what we feel and do are explained. There is a need to identify specific interpretations and predictions in order to question them.

• Exposure to the fears that underlie worry: consists of exposure to worrying images, including the vivid imagination of the worst feared consequence. The latter favors a greater emotional activation and the reduction of worries.
• Changing safety or defensive behaviors: Active avoidance behaviors should be prevented and activities that the client avoids doing (live exposure) should be encouraged.
• Time Organization: Teach skills to organize your time and set goals.
• Troubleshooting – The troubleshooting technique makes it easy to identify solutions to existing problems.

The intervention is spread over 12-15 one-hour weekly sessions, applied individually given the difficulties of making the exposition in groups based on imagination.

The most up-to-date version adds assertiveness treatment, medication interruption, and highlights the importance of the patient’s family participating in the intervention.

Dugas’ cognitive behavioral therapy

The Dugas group (Dugas and Koerner, 2005; Dugas and Ladouceur, 1997; Dugas and Robichaud, 2007; Robichaud, 2013) has proposed another type of intervention for GAD. This treatment has undergone some modifications over time.

Treatment modules

• Psychoeducation and training in “awareness” : differentiating between concerns based on reality and modifiable, based on reality and unmodifiable and based on highly unlikely events.

• Reassessment of the utility of worry : the intervention addresses the fact that the person overestimates the benefits of worrying, while underestimating its negative consequences.
• Problem solving training: For current problem concerns, problem solving is proposed. Problem solving training has two basic components: problem orientation and problem solving skills.
• Exposure, using the imagination, to the fears that underlie the worries: show the client that trying to avoid the thoughts can be counterproductive. For this, the white bear experiment can be used.

Added and / or improved in more recent versions of 2007

• Behavioral Exposure and Uncertainty Recognition: The primary goals of this module are for the client to understand the critical role of uncertainty intolerance in developing and maintaining excessive worry and anxiety.

• Relapse prevention: the knowledge and skills learned are reviewed and the need to continue practicing these skills is emphasized.

Finally, the patient is encouraged to develop an action plan before the end of therapy. You are encouraged to set goals to keep progressing without the help of the therapist.

Wells metacognitive therapy

Wells has suggested that GAD treatment should focus on addressing concerns. It is about addressing “the style of caring” rather than the content of the worries. The intervention includes:

• The individualized formulation of the case (functional analysis).

• Education about treatment, identification of two types of beliefs. Negative beliefs about worries and dysfunctional beliefs about the usefulness of the latter.
• The challenge of these beliefs through verbal restructuring and behavioral experiments.
• The elimination of the little adaptive strategies. An example is attempts at thought control, defensive behaviors, and avoidance. All of these strategies interfere with the self-regulation process and contribute to maintaining GAD.

End of treatment : review of alternative strategies to manage intrusions and stressors that trigger concerns.

Finally, let’s not forget that every concern is a warning sign, so that the way in which these concerns are generated has a lot to do with our ability to interpret reality and make inferences from the information that comes to us. When this alert system does not work well, either by issuing too few or too many – as we have seen in this article – the person suffers.