behavioral treatment of generalized anxiety disorder广泛性焦虑症的认知行为治疗课件

Cognitive Behavioral Treatment of Generalized Anxiety Disorder The original version of these slides was provided by Michael W. Otto, Ph.D. with support from NIMH Excellence in Training Award at the Center for Anxiety and Related Disorders at Boston University (R25 MH08478) Use of this Slide Set Presentation information is listed in the notes section below the slide (in PowerPoint normal viewing mode). A bibliography for this slide set is provided below in the note section for this slide. References are also provided in note sections for select subsequent slides. Slide Set Outline Treatment outcome findings Perspectives across meta analyses Treatment models Similarities (over differences) Elements of treatment What is accomplished in session Future directions Generalized Anxiety Disorder: Diagnostic Considerations Pervasive worry and chronic arousal Residual category of panic disorder in DSM-III Spheres of worry in DSM-III-R and chronic arousal Excessive and uncontrollable worry and 3 of 6 symptoms in DSM-IV restless, keyed up, on edge easily fatigued difficulties concentrating irritability muscle tension sleep disturbance Core Patterns in GAD Uncontrollable worry Future orientation Negative cognitive biases Somatic arousal Role and task inefficiency Interpersonal aversiveness (unbalanced relationships) GAD: Core Treatment Elements Information Applied Relaxation Cognitive Restructuring (probability estimates, coping estimates) Cue-Controlled Worry (worry times + problem solving) Worry Exposure (including existential topics) Mindfulness Meta-Analyses: 5 Perspectives All Randomized Trials (pre-post) Norton Borkovec et al., 2004) Intolerance of Uncertainty Model (Dugas et al., 1995; Freeston et al., 1994) Metacognitive Model (Wells, 1995) Emotion Dysregulation Model (Mennin et al., 2002) Acceptance-Based Model of Generalized Anxiety Disorder (Roemer Hoehn- Saric, McLeod, Lyonfields, Borkovec, Thayer, Friedman, Peasley-Miklus Hermans et al., 2009) Potential role for rumination in keeping CS UCS link alive Borkovec Encourage a present focus vs. future (past) Leave patients expectancy free Positive Beliefs About Worries Negative Problem Orientation Problems are threat to well-being Doubt about problem-solving ability Pessimism about problem solving outcome Negative problem orientation is more specific to worry than depression in student samples, and is differentiated from neuroticism (Robichaud e.g., Bernstein O st, 1987). AR does include exposure elements Mechanism of Relaxation Training (Ost, 1992) Reduces general tension and anxiety (and link stressor/panic) Enhances awareness about how anxiety works, de- mystifying and diminishing its impact Enhances self-efficacy : individuals feel equipped to cope with anxiety Relaxation Training Feel the difference between tension and relaxation Tense 7 seconds, relax 15 Specific muscle groups to learn the procedure Group them as skill increases Use 10-second relaxation cue The “Words” of Worry Non-specific and hard to dispute It will be horrible It will be a disaster Downward Arrow Techniques to clarify worries and put them in a form appropriate for cognitive- restructuring Cognitive Restructuring Self monitoring Logical analysis Probability overestimations Overestimations of the degree of catastrophe Ability to cope Relapse Prevention in Depression - Metacognitive Awareness Classic CT and mindfulness-based CT both enhance metacognitive awareness Level of metacognitive awareness is linked to relapse Changing the relationship people have to their thoughts, rather than changing beliefs, may be important for preventing relapse (Teasdale et al., 2002) Mindfulness Curious attention to the present moment, in an open, nonjudgmental, and accepting manner (Bishop et al., 2004; Germer, 2005; Kabat-Zinn, 1994) Why Mindfulness? Hayes and Feldman, 2004 Mindfulness training may enhance emotional regulation by addressing the patterns of over-engagement (e.g., rumination) and under-engagement (avoidance) that characterizes the disorder. Target is a healthy level of engagement that “allows clarity and functional use of emotional responses” Roemer et al, 2009 Non-clinical symptoms and clinical GAD status linked to lower mindfulness Worry Time Save up the worry (cue specificity) End of the day worry time In office (non-fun) setting 45 min with writing 10 min relaxation skills Go have fun GAD: Worry Exposure Metaphor: Like watching a scary movie over and over decreased arousal and changed meaning of the worry Apply exposure plus response prevention (including the use of tape loops) The goal is elimination of the worry response via repeated exposure to core fears This technique should also be coupled with the prescription to worry through one topic and not switch among “spheres of worry” GAD: Training in Normal Thinking Teach “normal thinking” as alternative behavior. What does one think about when not preoccupied with worry? Mindfulness of thinking states that are different from worry (e.g. daydreaming, experiencing, planning, enjoying) Sensory awareness training “Staying in the moment” Use of “worry times” Limited effects of exposure on valence/preference Attention ModificationTraining - GAD 29 treatment seeking patients Random assignment (train away vs. no train threat words) 8 sessions over 4 weeks Goal: Change attentional bias Change GAD symptoms Succeeded with both Between group effect size of .80 Least efficacy on worry (Amir et al., 2009, J Abn Psych) Attention Modification Training - GAD Randomized clinical trial GAD (N = 29) Stimuli: threatening or neutral words 50% of those in the active attention modification program were class