Treating Generalized Anxiety Disorder
Evidence-Based Strategies, Tools, and Techniques
By Jayne L. Rygh William C. Sanderson The Guilford Press
Copyright © 2004 The Guilford Press
All right reserved. ISBN: 1-59385-039-5
Chapter One
Worry Episode Log (for Assessment) The assessment version of the Worry Episode Log (see Handout 3.2) heightens awareness (in both therapist and client) of the elements of worry in the individual client. Clear identification of all active individual components during episodes of worry illuminates specific points for treatment intervention. In addition, the log can be used to create treatment hierarchies (as discussed in Chapter 7). A modified version of this log is used in the treatment phase and is discussed in Chapter 5.
Several important pieces of information should be filled out on this form in the assessment phase. The day, date, and time of the worry episode should be noted. Although the log can be completed in retrospect, this is not ideal; retrospective completion may not be as accurate as an immediate response, because recall biases increase with the passage of time. Internal and external stimuli (triggers) associated with the onset of worry are important to include. The intensity of anxiety, amount of control over worry, and the experience of any other emotions during the worry episode are to be recorded. Most important to note are thecognitive (images, thoughts, assumptions, and beliefs), physiological, and behavioral activities that occur during the episode of worry. Lastly, the duration of the episode is entered. The following clinical vignette provides an example of the therapist instructing the client on how to complete this form.
Therapist: Let's take your last episode of worry in hand. What was happening when you first noticed yourself worrying?
Client: I was in my car, coming here. There was much more traffic than usual. I was feeling totally overwhelmed and distressed, thinking, "Oh, my God, I am going to be late."
Therapist: OK. So write down today's day, date, and the time of the episode on this form. I want you to rate the intensity of your anxiety or worry while you were in this situation. Using this 0-8 scale on the top of this sheet, with 0 representing no anxiety or worry, 2 representing a mild level, 4 as moderate, 6 as severe, and 8 as extreme, how would you rate what you felt at that time?
Client: About 7.
Therapist: You were pretty anxious. OK. Circle the 7. How much control did you have over the worry in this situation?
Client: What do you mean?
Therapist: Do you think you could have stopped yourself from worrying?
Client: No. I was too anxious about getting here late.
Therapist: Try to rate the degree of control over worry, again using the 0-8 scale at the top of this sheet. 0 represents no control, and the numbers go up to 8. An 8 indicates complete control. How much control over worry did you feel in this situation? Client: I guess about 1.
Therapist: OK. Circle 1. Were you feeling any other emotions in this situation, like anger or sadness or any other emotion?
Client: Maybe a bit of anger, because I have too much to do.
Therapist: OK. Write that emotion down and rate it on the 0-8 scale.... Do you remember what was happening when you noticed your anxiety beginning to rise?
Client: (Pause) ... The traffic started to get heavy, and it was slowing me down.
Therapist: Good. Write that down next to "Worry triggers." Did you have any images while this was occurring?
Client: Yeah. I was imagining that you would be really angry about the lateness. I feel embarrassed telling you this. It sounds so ridiculous now. I should be able to handle these situations in a mature fashion without having to get help.
Therapist: I am really glad that you are telling me this. Feeling embarrassed about revealing what goes on inside of you during these times is something that I hear very frequently from clients at the initial stages of treatment. It sounds like part of you wants to hide and feels like you should be beyond this; yet another part of you is ready to risk exposing some of this stuff so that you can get help. I want to appeal to the side of you that is willing to take some risks. How about using this session as an experiment to see how you feel at the end of the session after taking the risk of exposing what's going on inside of you?
Client: OK.
Therapist: So write down under "Mind," next to "Images," the image of an angry therapist. In therapy, we define "cognition" as any image, thought, assumption, or belief that runs through your mind. Sometimes these cognitive events occur very quickly and are difficult to catch. Did you notice anything else running through your mind at that time?
Client: I assumed you'd tell me that I'm not a good candidate for therapy, given that I couldn't get here on time. I was thinking, "This whole situation is intolerable, because I have to get help." I also was thinking that I probably wasted time and put myself under even more intense pressure by coming here, rather than less.
Therapist: OK. Write all this down under "Mind," next to "Thoughts, assumptions, beliefs": "I assumed I would be told I was not a good candidate. I thought the situation was intolerable. I thought I probably wasted time and put myself under even more intense pressure."
Therapist: What kind of beliefs did you have about yourself when this was occurring?
CLIENT: (Pause) ... I'm always making mistakes. Whatever I do is never good enough. I should have left earlier to make sure I got here on time.
Therapist: What about beliefs about others in relation to you?
Client: I guess that mistakes are not OK. You get rejected if you don't behave correctly.
Therapist: What about beliefs about situations like this?
Client: I guess that something is always going wrong. Life is so unpredictable.
Therapist: What do you believe about the process of worry in these types of situations? Why worry?
Client: Worry keeps me more focused on what I'm doing. In this situation, I thought it would get me here faster. I also thought that you might be more forgiving of my tardiness if you saw how serious I was about getting here.
Therapist: Write those beliefs down next to your thoughts and assumptions. You can write, "Whatever I do is never good enough. I get rejected by others when I make mistakes. Life is unpredictable. Worry keeps me focused on what I'm doing. My worry makes others more forgiving of my mistakes." ... At the time that all of this was occurring, how strongly did you believe these cognitions were true, on a 0-8 scale?
Client: About 7.
Therapist: Write down that rating where it says "Rate how convincing ..." in parentheses. (Pause) ... It sounds like you were experiencing a lot of anxiety with those cognitions, which were very believable to you. What were the physical sensations or symptoms you were experiencing in this situation?
Client: I was really tense. I think my chest felt tight. I was taking a lot of deep breaths.
Therapist: Were you breathing like this (demonstrates large breaths through the chest) or like this (demonstrates deep diaphragmatic breaths)?
Client: Definitely the first.
Therapist: OK. Write down "Tense, tightness in chest, large chest breath" next to "Body." What were you doing in this situation?
Client: I started checking the clock every 20 to 30 seconds. I started weaving in and out of traffic trying to get ahead. I was yelling at all the cars ahead of me. No one could hear me, of course, because I had the windows shut. I ran several yellow lights-actually, one had just turned red-on my way here. Fortunately, no cops were around.
Therapist: OK. Next to "Actions/behaviors," write down each of those behaviors.... It sounds like you were responding on a number of levels as if you were in an emergency situation.
Client: Yeah. I was. I could have gotten a ticket or had an accident with the way I was driving.
Therapist: It sounds like you temporarily lost sight of the relative importance of different priorities-getting to this appointment on time, versus driving safely to prevent injury to yourself or others.
Client: That definitely is true, and that kind of thing makes me even more worried. Looking back at how I was thinking and what I did, I really feel like I'm not in control at those times.
Therapist: The last section is for writing down the duration of the episode. How long did this episode last?
Client: Well, I'm not sure. I got here on time, so that worry disappeared. But, I started worrying that you were going to think I was a real nut job once I got in here.
Therapist: OK. That sounds like an even more recent, but different, episode of worry. That worry would be recorded on a separate log sheet. When did you stop worrying about being late?
Client: When I got here at 7:58 P.M.
Therapist: So this episode lasted how long?
Client: I guess about 30 minutes.
Therapist: Write that down.... We just worked through this form retrospectively, and that can be helpful. The most helpful time to fill out this form, though, is during an episode of worry. The only item that must be done retrospectively is the duration of the episode. It is very important that you begin to record episodes of worry on copies of this form.
There are two advantages in filling out this form during an episode. First, observing and recording an episode will allow you to slow down and interrupt the process of worry. Right now, the process is occurring quickly and automatically. Sometimes the process may be so quick that you may miss some of the elements of worry. You may find that you have to really concentrate to catch what is occurring at these times. The benefit of careful recording is that the recording allows you to gain some distance from the worry. This distance will make it easier to recognize when and where you can implement techniques to reduce worry. You will be learning a variety of techniques for this purpose. Second, completing a copy of this form whenever you have a worry episode will speed up your treatment. The more quickly we can assess the problem areas, the sooner we can begin to systematically apply techniques in those areas.
I know that sometimes you won't be able to fill out this form during an episode. In those instances, try to record the episode retrospectively. If you do it retrospectively, carefully retrace the sequence of events as they occurred. Complete the form as soon as possible. The longer you wait, the more difficult it will be to remember accurately what happened during the episode.
Your assignment for next week is to fill out the Worry Diary at the end of every day, and to complete a Worry Episode Log whenever you notice an episode of worry occurring. We will be using the information that you collect on these forms in our next session. [See Chapter 4, p. 73, for ways to address noncompliance with filling out these forms.]
Figure 3.2 shows a Worry Episode Log completed by Richard for another episode.
ASSESSING PROBLEMATIC PATTERNS IN PAST AND CURRENT RELATIONSHIPS
Poor-quality interpersonal relationships are an important complicating factor in treatment. If other assessments so far have indicated significant relationship problems, the further assessment of these is helpful.
There are several methods for assessing interpersonal difficulties. These include administering the Inventory of Interpersonal Problems Circumplex Scales (IIP-C), looking for patterns across relationships in the client's life, conducting an in-depth exploration of one important relationship, and using the therapist's own emotional experience with the client to identify problematic interpersonal behaviors. All of these types of assessment can be included as part of the initial assessment. The last type of assessment can also be conducted throughout the course of treatment.
The IIP-C is a self-report measure that was developed by Alden, Wiggins, and Pincus (1990). This instrument has eight scales (Domineering/Controlling, Vindictive/Self-Centered, Cold/Distant, Socially Inhibited, Nonassertive, Overly Accommodating, Self-Sacrificing, and Intrusive/ Needy) for assessing interpersonal problems. The IIP-C has strong test-retest reliability (total r =.98; average subscale r =.81) and good alpha (.72-.85) coefficients. On this instrument, individuals with GAD report more interpersonal distress and rigidity than do nonanxious controls. Cluster analyses cited by Borkovec, Alcaine, and Behar (2004) indicated interpersonal styles of being overly nurturing and intrusive (62.1% of clients with GAD). Cold and vindictive, and socially avoidant and nonassertive interpersonal styles were indicated by smaller clusters.
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Excerpted from Treating Generalized Anxiety Disorder by Jayne L. Rygh William C. Sanderson Copyright © 2004 by The Guilford Press. Excerpted by permission.
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