广泛性焦虑障碍

Contains V nto ral Cent avior tocol i ) wor (4) p plica arch appe GAD in c resp diso therapy, and acceptance-based behavioral therapy (see this issue for illustrations of each), the present paper will nd U): development and maintenance of excessive worry. Specif- ically, it is posited that individuals with GAD hold negative 1 Video patients/clients are portrayed by actors. Cognitive and Behavioral Pract beliefs about uncertainty and its implications on their lives, wherein uncertain events are viewed as negative, stressfulKeywords: generalized anxiety disorder; cognitive-behavior therapy; effectiveness (Dugas, Anderson, et al., 2010). In the past few decades, however, a number of research teams have begun to develop treatment protocols for GAD that are derived from empirically driven theoretical formulations of the disorder. This positive shift in the study of GAD can be The CBT-IU protocol for the treatment of GAD addresses four components: (a) intolerance of uncertainty, (b) positive beliefs about the function of worry, (c) negative problem orientation, and (d) cognitive avoidance. It is based upon a cognitive theory of the disorder that gives primacy to the role of intolerance of uncertainty in the intol 1077 © 20 Publ s a circumscribed trigger for anxiety. Moreover, it ars that despite the challenges in our understanding of , it has received comparatively little scientific attention ontrast to other anxiety disorders, particularly with ect to process research that might better elucidate the rder's underpinnings and thereby maximize treatment focus only on CBT-IU and associated measures a interventions as it applies to a clinical case of GAD. Cognitive-Behavior Therapy Targeting IU (CBT-I Theory and Research CBT-IU Rationale Cognitive Behavior Therapy Targeting I a Clinical Case of Gene Melisa Robichaud, Vancouver CBT The present paper deals with the application of a cognitive-beh hypothetical clinical case of GAD. The rationale for the CBT-IU pro cognitive-behavioral interventions. The treatment components of (1 (3) reevaluation of positive beliefs about the function of worry, (6) relapse prevention are described, with an emphasis on their ap issue). Issues pertaining to the assessment of GAD and future rese G ENERALIZED anxiety disorder (GAD) has consistentlybeen viewed as one of the more challenging anxiety disorders, as it can be markedly difficult to appropriately assess and treat. Research on diagnostic reliability suggests that GAD is often misdiagnosed, and treatment efficacy for the disorder is moderate at best, with only approximately 50% of patients identified as having positive outcomes (Borkovec & Costello, 1993; Borkovec, Newman, Pincus, & Lytle, 2002). Reasons accounting for this include the shifting diagnostic criteria for GAD across successive editions of the DSM, and the vague nature of its primary symptom (i.e., excessive and uncontrollable worry), which lack erance of uncertainty; clinical case series -7229/12/251-263$1.00/0 12 Association for Behavioral and Cognitive Therapies. ished by Elsevier Ltd. All rights reserved. ideo 1 lerance of Uncertainty: Application to ized Anxiety Disorder re and University of British Columbia al protocol targeting intolerance of uncertainty (CBT-IU) to a s presented, as well as a description of its divergence from standard ry awareness training, (2) uncertainty recognition and exposure, roblem reorientation and training, (5) cognitive exposure, and tion to the case conceptualization of “William” (Robichaud, this directions are also discussed. expected to ultimately increase the effectiveness of psychological treatments for those suffering from the disorder. The present article deals with the exposition of one such protocol, a cognitive-behavioral treatment for GAD for which the central target is the construct of intolerance of uncertainty (IU), as well as its application to the clinical case of “William” (Robichaud, 2013–this issue). Although there are currently several evidence-based treatments for GAD, including metacognitive therapy, emotion regulation ice 20 (2013) 251-263 www.elsevier.com/locate/cabp and upsetting, and that they interfere with one's ability to function. As such, the overarching theme of threat among individuals withGAD is the general state of uncertainty, and the correspondent worry in GAD is a mental attempt to 252 Robichaud plan and prepare for any eventuality as ameans of reducing uncertainty. However, since daily life is inherently uncer- tain, individuals with GAD are constantly engaged in worry. Furthermore, the content of worry can be expected to change from day to day according to the particular uncertain situations that an individual experiences, thereby accounting for the dynamic nature of worry content. Within the CBT-IU model, fear of uncertainty is postulated to not only lead to excessive worry and anxiety about daily life events, but also to a number of dysfunctional coping behaviors. Specifically, individuals withGADengage in safety-seeking behaviors designed to either reduce uncertainty or avoid it altogether. Examples include reassurance-seeking, double-checking, or excessive infor- mation-seeking, as well as procrastination and avoidance of novel situations. Through negative reinforcement, these behaviors maintain the belief that uncertainty is an undesirable state that should be minimized as much as possible in order to function optimally in daily life. Individuals with GAD have also been found to report positive beliefs about the function of worry, viewing worry as a process that can, for example, assist one in solving problems or reflect positively on someone as a caring or conscientious person. These positive beliefs are expected to not only maintain worry through its perceived use as a viable strategy in uncertain situations, but also produce ambivalence about the prospect of reducing one's worry. Negative problem orientation (NPO), that is, the tendency to hold negative beliefs about problems and one's own ability to solve them, is also posited to maintain worry. Individuals with GAD tend to doubt their problem- solving competence, and view problems as threatening and unlikely to be effectively resolved. Given that holding a negative perception about one's ability is unlikely to lead to problem solving irrespective of actual ability, individuals with GAD are more likely to avoid solving problems, ask others to solve them, or worry about their problems rather than addressing them. As a consequence, daily life problems become a frequent worry topic, and if left unsolved, can become more complex or engender new difficulties, such that new worries can develop. Finally, individuals withGADare also viewed as engaging in a number of explicit and implicit cognitive avoidance strategies designed to reduce anxious arousal. With respect to implicit cognitive avoidance, themental process of worry tends to be verbal-linguistic rather than visual, in that worry is mentally expressed in words rather than images. This internal monologue inhibits the somatic activation that is typically achieved by mentally picturing feared events, thereby negatively reinforcingworry through the avoidance of feared imagery and physiological arousal (see Borkovec, Alcaine, & Behar, 2004, for review). Explicit cognitive avoidance strategies include distraction, thought suppres- sion, and thought replacement (Sexton & Dugas, 2009). These strategies typically have only limited success at best, and as with implicit avoidance, maintain worry in the long term through avoidance of somatic arousal. Moreover, strategies such as thought suppression tend to engender a rebound effect that paradoxically increases the frequency of suppressed thoughts (Wegner & Zanakos, 1994). Research Findings Intolerance of uncertainty has been found to share a strong and specific relationship to GAD worry, above and beyond its relationship to cognitive symptoms in other anxiety and mood disorders (e.g., Buhr & Dugas, 2006; Dugas, Gosselin, & Ladouceur, 2001). Although several studies have identified a significant relationship between IU and other anxiety disorder symptoms such as OCD and social anxiety disorder (Boelen & Reijntjes, 2009; Tolin, Abramowitz, Brigidi, & Foa, 2003), the weight of the evidence suggests nonetheless that IU shares a prominent and specific relationship to GAD. It is postulated that although uncertainty is likely aversive to all individuals with problematic anxiety to some extent, it is the general state of uncertainty that is threatening to those with GAD, as opposed to more circumscribed uncertainty fears in other anxiety disorders (e.g., intolerance of uncertain social situations in social anxiety disorder). The three remaining process variables within the CBT-IU model have also been consistently linked to GAD symptoms; however, their relationship does not appear to be specific to GAD (see Dugas & Robichaud, 2007, for review). With respect to the efficacy of the CBT-IU protocol, a number of controlled clinical trials have been conducted. The treatment has been compared to wait-list control in both individual and group formats, and significant re- ductions in symptom measures were observed at both posttreatment and follow-up. In individual format, 77% of GAD participants (N=26) no longer met diagnostic criteria at posttreatment, with 65% meeting high treatment responder status (20% change on at least two thirds of outcome measures) and 62% achieving high end-state functioning (within nonclinical range on at least two thirds of outcomemeasures). At 1-year follow-up, these gains were largely maintained, with 77% of participants continuing to be in diagnostic remission, and 62% and 58% being high treatment responders and achieving high end-state func- tioning, respectively (Ladouceur et al., 2000). In group treatment, 60% of GAD participants (N=52) no longermet diagnostic criteria at posttreatment, 65% met high treat- ment responder status, and 60% met high end-state functioning (Dugas et al., 2003). Treatment gains were not only maintained but improved at follow-up, with diagnostic remission rates of 83% at 1-year and 95% at 2-year follow-up, and 72% of participants meeting both treatment responder status and high end-state functioning at 2-year follow-up. Subject attrition was considerable in this 253CBT Targeting Intolerance of Uncertainty for GAD latter study, however, with 39 participants completing 2-year outcome measures, such that these findings may be an inflation of overall gains. In a recent randomized clinical trial, CBT-IU was compared to both wait-list and applied relaxation (AR) in an individual treatment format (N=65). CBT-IU emerged as clearly superior to wait-list, and marginally superior to AR, although ongoing gains at posttreatment only emerged for participants who received CBT-IU. Remission rates forCBT-IUwere 70%at posttreatment, 76%at 6-month follow-up, 84% at 12-month follow up, and 77% at 24-month follow-up (Dugas, Brillon, et al., 2010). The authors noted that despite the significant symptom reduction observed among those receiving AR, CBT-IU appeared to be superior over the longterm, as those receiving it demonstrated ongoing improvement in both symptom measures and diagnostic remission, which may be due to the gradual process of change within one's tolerance to uncertainty. Contrast to Standard CBT Protocols There are a number of cognitive-behavioral strategies that have been used in the treatment of GADover the years; these have included cognitive challenging techniques, such as probability estimation and decatastrophizing (e.g., Zinbarg, Craske,&Barlow, 2006), as well as behavioral interventions, such as applied relaxation, stimulus control, and imagery rehearsal (see Borkovec, 2006, for review). A notable distinction between these interventions and the CBT-IU protocol is the treatment target. Specifically, cognitive interventions address the problematic content of worry by encouraging clients to reevaluate the likelihood and severity of feared events. With respect to behavioral interventions, the target is the chronic somatic arousal experienced in GAD, such that clients can learn to apply physical relaxation when experiencing anxiety. In both cases, treatment focuses on the problematic symptoms of GAD rather than the underlying processes accounting for their presentation. Given the dynamic and ever-changing nature of worry topics, as well as the chronicity of anxiety in GAD, these interventions involve essentially chasing a “moving target.” By contrast, the primary component of CBT-IU addresses the intolerance to uncertainty that is posited to account for GAD symptoms, such that once clients no longer fear and avoid uncertain events, they are unlikely to worry excessively. The remaining CBT-IU interventions, which target positive beliefs about worry, negative problem orientation, and cognitive avoidance, are not unique to this protocol, and in fact can be seen in other empirically based treatments. Specifically, beliefs about worry are a primary focus of metacognitive therapy (Wells, 2006), problem-solving training has been used as a treatment for anxiety and mood symptoms (D'Zurilla & Nezu, 1999), and imaginal exposure to feared worry content has been included in several CBT protocols for GAD (Zinbarg et al., 2006). Moreover, these components address the content of worry rather than its underpinnings. As such, although the main thrust of the CBT-IU protocol involves targeting uncertainty as the underlying theme of threat that elicits excessive worry, interventions such as worry exposure and problem solving are postulated to address any residual concerns in an active manner that is in sharp contrast to the passive process of worry. Application of the CBT-IU Model to Clinical Case Conceptualization Specific Assessment Strategies Assessment for clients with GAD falls into two categories: symptom and process. With respect to symptoms, excessive worry can be measured using the Penn State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger, & Borkovec, 1990). ThePSWQ is a 16-itemquestionnaire designed to assess the traitlike tendency toworry. Ithasbeenextensively validated (see Startup & Erickson, 2006) and has clinical cutoff and normative data such that it can be administered throughout treatment. Global self-reportmeasures of GAD symptomsmay also be completed across treatment sessions; the Worry and Anxiety Questionnaire (WAQ; Dugas, Freeston, et al., 2001) and the Generalized Anxiety Disorder Questionnaire–IV (GADQ-IV; Newman et al., 2002) are both relatively short measures that can be administered repeatedly to assess worry, GAD-related somatic criteria, and associated impairment. There are a number of validated process measures that assess constructs specific to conceptualmodels ofGAD.With respect to the CBT-IU protocol, the following measures can be administered: (a) the Intolerance of Uncertainty Scale (IUS; English translation: Buhr & Dugas, 2002) assesses the tendency to hold negative beliefs about uncertainty and its implications; (b) the Why Worry-II (WW-II; English translation: Holowka, Dugas, Francis, & Laugesen, 2000) measures positive beliefs about the function of worry (e.g., worry aids in problem solving); (c) the Negative Problem Orientation Questionnaire (NPOQ; English translation: Robichaud & Dugas, 2005) assesses the dysfunctional cognitive dimension of problem orientation, namely the tendency to view problems as threats, to be pessimistic about theoutcomeof problem solving, and todoubt one's ability to solve problems; and (d) the Cognitive Avoidance Question- naire (CAQ; English translation: Sexton & Dugas, 2008) measures implicit and explicit cognitive avoidance strategies (e.g., thought substitution, distraction). Taken together, these questionnaires can provide clinicians with insight into the prominence of the CBT-IU variables for a given client, and inform subsequent treatment interventions. Translation of CBT-IU Model to the Case of William With respect to the CBT-IU model as it applies to the clinical case of William (Robichaud, 2013–this issue), the 254 Robichaud primary contributing role of intolerance of uncertainty is present throughout. William reports worrying excessively about a number of topics that are inherently uncertain, such as the possibility of becoming ill one day, the family finances should he pass away suddenly, and his daughter's academic future. Although his worries have been long- standing, the severity and frequency of his worries appear to have increased over the years in tandemwith an increase in his responsibilities. Specifically, his worries became more problematic after taking a position as a bank manager, as well as after the birth of his daughter. Assuming that worry in GAD is driven by uncertainty, an increase in responsi- bilities would be expected to lead to a concomitant increase in potentially uncertain events, thereby exacerbating worry. William also reports engaging in a number of safety- seeking behaviors designed to avoid or circumvent uncertainty in his daily life. For example, he describes seeking reassurance from others and engaging in lengthy informational searches on the Internet prior to making decisions. He also engages in procrastination, refuses to delegate tasks to others, avoids spontaneous outings, and maintains a predictable routine in his day in order to reduce uncertainty about the occurrence of unexpected events. The futility of attempting to avoid uncertainty, and the ultimate impairment it leads to, is evident in William's case both in terms of daily life decisions for which certainty is impossible, and in the escalation of his symptoms to a nonfunctional degree. In the example of William's struggle with home landscaping, he initially engages in safety-seeking behaviors designed to obtain certainty about the best flowers to plant (e.g., excessive reassurance-seeking, information-- seeking). However, the greater the amount of information garnered, the greater the uncertainty about what choice to ultimately make. As a consequence, William switched to an avoidance strategy by hiring a landscape designer and removing himself from the decision-making process entirely. The marked increase in William's worry and anxiety also appears to be fueled by uncertainty. He describes experiencing worry-triggered panic attacks and is contemplating medical leave, as he is feeling overwhelmed by tasks at work subsequent to a job change. If worry is conceptualized asmotivated by a need to mentally plan and prepare for any unexpected eventuality, the cognitive effort required can be expected to be significant on an ordinary day. However, when stressful events occur, the resultant uncertainty can greatly exacerbate worry to an unmanage- able degree, as appears to be the case with William. In addition to a marked intolerance of uncertainty, William also endorses a number of positive beliefs about the function of worry. He describes himself as “the worrier,” and associates this with the positive personality traits of conscientiousness and organization. He indicates that his worries allow him to better address problematic situations at work, as he is able to consider all angles. The ambivalence that William experiences in relation to his worry is evident by the juxtaposition of both these perceived benefits from worry and his report that his worry is problematic, anxiety-provoking, and interferes with his enjoyment of life. Although not specifically discussed in William's case, it can be postulated that he holds a negative orientation toward problems. Specifically, as his workload in his job increases, he describes becoming increasingly overwhelmed and procrastinating as a means of coping. In addition, when faced with decisions that he finds anxiety-provoking (e.g., home landscaping), he avoids addressing the p