babcp conference spring babcp conference spring ’04’04

“I can’t get it out of my “I can’t get it out of my head”head”investigating/treating unwanted intrusions &

ruminations eight speakers variety of disorders tom borkovec gave the keynote talk on

GAD and worry next day, a choice of several workshops I went to tom’s on

adding emotional & interpersonal

elements to GAD CBT treatment

I contacted tom after the I contacted tom after the workshop: usa visit?workshop: usa visit?

he was hugely welcoming & helpful

so last autumn I flew off to to penn state university for a week

... and hence this ‘buzz’ session

today

tom tom borkovecborkovec

professor of psychology at penn professor of psychology at penn state universitystate university

twenty years of fine research to twenty years of fine research to improve our understanding & improve our understanding & treatment of GADtreatment of GAD

his penn state web page lists 30 his penn state web page lists 30 articles & book chapters published articles & book chapters published (or in press) in the last 3 years(or in press) in the last 3 years

of particular ‘buzz’ for me are two of particular ‘buzz’ for me are two research developments in his work research developments in his work

one is the his exploration of what one is the his exploration of what the ‘severe normality’ of GAD can the ‘severe normality’ of GAD can tell us about ‘normal’ mind statestell us about ‘normal’ mind states

...the other is his research on ...the other is his research on adding emotional & adding emotional &

interpersonal components to the interpersonal components to the cbt treatment of gadcbt treatment of gad Borkovec, T.D., Newman, M.G., Pincus, A., & Lytle, R.Borkovec, T.D., Newman, M.G., Pincus, A., & Lytle, R. A component A component

analysis of cognitive behavioral therapy for generalized anxiety analysis of cognitive behavioral therapy for generalized anxiety disorder and the role of interpersonal problems. disorder and the role of interpersonal problems. J Consult Clin J Consult Clin Psychol 2002; 70:Psychol 2002; 70: 288-298288-298

Borkovec, T.D., Newman, M.G., & Castonguay, L.G. Cognitive-Cognitive-behavioral therapy for generalized anxiety disorder with behavioral therapy for generalized anxiety disorder with integrations from inter-personal and experiential therapiesintegrations from inter-personal and experiential therapies. CNS Spectrum 2003; 8: 382-389

Newman, M.G., Castonguay, L.G., Borkovec, T.D., & Molnar, C.Newman, M.G., Castonguay, L.G., Borkovec, T.D., & Molnar, C. Integrative therapy for generalized anxiety disorder. Integrative therapy for generalized anxiety disorder. In R.G. In R.G. Heimberg, C.L. Turk, & D.S. Mennin (Eds.),Heimberg, C.L. Turk, & D.S. Mennin (Eds.), Generalized anxiety disorder: Advances in research and practice, , pp. 320-350. New York: Guilford Press, 2004

Castonguay, L. G., Newman, M. G., Borkovec, T. D., Holtforth, M. G., & Maramba, G. G. (in press). Cognitive-behavioral assimilative integration. In M. Goldfried & J. Norcross (Eds). Handbook of psychotherapy integration. Oxford: Oxford University Press

why is gad important?why is gad important? high prevalence:high prevalence: office of national statistics uk reported in office of national statistics uk reported in

2000 that besides a ‘catch-all’ mixed anxiety & depressive 2000 that besides a ‘catch-all’ mixed anxiety & depressive disorder diagnosis, GAD at a current prevalence of 4.4% is the disorder diagnosis, GAD at a current prevalence of 4.4% is the most common neurotic disorder – more common than most common neurotic disorder – more common than depressive episode, phobias, OCD, or panicdepressive episode, phobias, OCD, or panic

considerable morbidity:considerable morbidity: GAD is associated with GAD is associated with considerable suffering & reduced quality of life, major considerable suffering & reduced quality of life, major increases in GP consultations & health care costs, and increases in GP consultations & health care costs, and extensive time off workextensive time off work

chronicity: a systematic review found that only 25% would a systematic review found that only 25% would be in full remission at 2 year and only 38% at 5 year follow-up be in full remission at 2 year and only 38% at 5 year follow-up

comorbidity: GAD is highly comorbid with other disorders GAD is highly comorbid with other disorders such as major depression, but the GAD tends to predate and such as major depression, but the GAD tends to predate and increase vulnerability to the subsequent comorbid disorderincrease vulnerability to the subsequent comorbid disorder

the basic anxiety disorder:the basic anxiety disorder: Professor David Barlow has Professor David Barlow has written that GAD may be the “basic” anxiety disorder, with written that GAD may be the “basic” anxiety disorder, with increased understanding of GAD having implications for all increased understanding of GAD having implications for all anxiety disordersanxiety disorders

gad: worry, anxiety & gad: worry, anxiety & tensiontension

frequent distressing worry that’s difficult to control about many things that might go wrong in the future

restlessness, irritability, muscle tension, fatigue,difficulty concentrating,and sleep disturbance

more ‘freeze’ than ‘fight or flight’: thoughts more than images, unhappy but not strongly in touch with emotions, or with the present moment

successful cbt approach for successful cbt approach for gadgad

self-monitoring for early signs self-monitoring for early signs of anxiety and tension of anxiety and tension

training in calming skills, training in calming skills, application during daily life, application during daily life, and coming into the presentand coming into the present

using imaging to encourage using imaging to encourage use of calming skills and use of calming skills and cognitive coping strategiescognitive coping strategies

cognitive coping strategies include cognitive coping strategies include worry tree, worry outcome worry tree, worry outcome diary, worry problem solving times, diary, worry problem solving times, worry-free zones, beliefs about worry-free zones, beliefs about worry, etcworry, etc

... but better results ... but better results welcomewelcome

despite getting as good results as any despite getting as good results as any other research team, post treatment 50% other research team, post treatment 50% of clients are still not within normal rangeof clients are still not within normal range

in tom borkovec’s third major research in tom borkovec’s third major research study using CBT for generalized anxiety study using CBT for generalized anxiety (GAD III), it was found that having more (GAD III), it was found that having more interpersonal problems predicted a less interpersonal problems predicted a less successful response to CBT successful response to CBT

it was already known that worry at times it was already known that worry at times acted as avoidance of images & emotionsacted as avoidance of images & emotions

the IIP questionnaire suggested possible the IIP questionnaire suggested possible difficulties in current relationships, and difficulties in current relationships, and there were frequent problems in there were frequent problems in upbringing and relationships with parents upbringing and relationships with parents as wellas well

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2.6 2.69 2.8

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2

2.5

3

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GAD IA GAD IB GAD II GAD III GAD IV

within-group effect sizes for gad research from tom borkovec's team at penn state

for GAD IV, added I/EP to CBTfor GAD IV, added I/EP to CBT

plus plus deepeningdeepeningemotional emotional

& inter-& inter-personalpersonal

contact with contact with self & othersself & others

plus plus living living

more tomore toour ownour own

innerinnervaluesvalues

plus plus focusfocuson theon the

presentpresentmomentmoment

cbt involving applied cbt involving applied relaxation, imagery relaxation, imagery methods & various methods & various

cognitive challengescognitive challenges

the components of the components of interpersonal & emotional interpersonal & emotional

processing therapyprocessing therapy

relevance of upbringingrelevance of upbringingtraumatic events with otherstraumatic events with othersunresolved earlier relationshipsunresolved earlier relationshipsnature of current friendshipsnature of current friendshipsother role relationships other role relationships

e.g. work, couple, parent, etc e.g. work, couple, parent, etc

the penn state I/EP therapy focuses on:

it’s high time for a broader it’s high time for a broader integration of interpersonal integration of interpersonal

& emotional components & emotional components into cbtinto cbt Coyne JC. Coyne JC. Thinking postcognitively about depression. Thinking postcognitively about depression. In: Freeman A, Simon KM, In: Freeman A, Simon KM,

Beutler LE, Arkowitz H, editors. Beutler LE, Arkowitz H, editors. Comprehensive handbook of cognitive therapy.Comprehensive handbook of cognitive therapy. New New York: Plenum, 1989. p 227-44York: Plenum, 1989. p 227-44

Gotlib IH, Hammen CL. Gotlib IH, Hammen CL. Psychological aspects of depression: towards a cognitive-Psychological aspects of depression: towards a cognitive-interpersonal integration.interpersonal integration. Chichester: John Wiley, 1992 Chichester: John Wiley, 1992

Safran J, Segal Z. Safran J, Segal Z. Interpersonal process in cognitive therapy.Interpersonal process in cognitive therapy. Northvale, NJ: Jason Northvale, NJ: Jason Aronson, 1996.Aronson, 1996.

Castonguay LG, Goldfried, M.R. et al. Castonguay LG, Goldfried, M.R. et al. Predicting the effect of cognitive therapy for dep-ression: a study of unique and common factors. J Consult Clin Psychol 1996;64:497-504. 1996;64:497-504.

Hayes AM, Castonguay LG, et al. Hayes AM, Castonguay LG, et al. Effectiveness of targeting the vulnerability factors of Effectiveness of targeting the vulnerability factors of depression in cognitive therapy.depression in cognitive therapy. J Consult Clin Psychol 1996; 1996; 64: 623-7.: 623-7.

Safran J, Muran JC. Safran J, Muran JC. Negotiating the therapeutic alliance. Negotiating the therapeutic alliance. New York: Guilford Press, New York: Guilford Press, 2000.2000.

Klein DN, Schwartz JE, et al. Klein DN, Schwartz JE, et al. Therapeutic alliance in depression treatment: controlling for prior change and patient characteristics. J Consult Clin Psychol 2003; 71: 997-1006. 2003; 71: 997-1006.

Greenberg LS. Greenberg LS. Emotion-focused therapy.Emotion-focused therapy. Washington, DC: Am Psych Ass’n, 2002. Washington, DC: Am Psych Ass’n, 2002. Castonguay LG, Newman MG, Borkovec TD, Holtforth MG, & Maramba GG. (in press).

Cognitive-behavioral assimilative integration. In M. Goldfried & J. Norcross (Eds). Handbook of psychotherapy integration. Oxford: Oxford University Press