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Cognitive Behavioral Therapy and Generalized Anxiety


Permission graciously given by the author to reproduce this paper. 
 

Cognitive Behavioral Therapy

in the Treatment of Generalized Anxiety Disorder

Joy Bishop
2006 

According to the DSM-IV-TR (American Psychiatric Association, 2000), Generalized Anxiety Disorder (GAD) is a condition that is characterized by excessive anxiety and worry about situations, events, or activities for the majority of days during at least a 6 month period.  Worries include everyday routine situations and experiences such as job performance, family/home responsibilities, finances, relationships, children, social obligations, etc.  Although everyone in life faces daily problems, the person with GAD is unable to control the worry and perceives life events or situations out of proportion to any realistic or truly hazardous threat. Individuals with GAD may not always identify their anxiety as excessive, however, their reported subjective feelings confirm significant distress and their ability to function is impaired (National Institute of Mental Health, 2006).  Common symptoms related to GAD can be psychological, emotional, physical, or behavioral in presentation and include: persistent troublesome thoughts, feelings of dread,  restlessness, inability to relax, easy to startle, twitching or trembling, muscle tension, muscle aches, headaches, chest pains, stomach ache, nausea, diarrhea, grinding teeth, dry mouth, sweating, hot flashes, dizziness, lightheadedness, irritability, difficulty sleeping, fatigue, lack of energy, concentration difficulties, and  procrastination (National Institute of Mental Health, 2006).    

Throughout this course we have been investigating how the mind is able to affect the physical body. Numerous studies have demonstrated that stress is linked to a variety of negative health outcomes, with researchers and public health officials becoming increasingly interested in understanding the nature of this relationship (National Institutes of Health, 2003). Since generalized anxiety disorder (GAD) is often a persistent and unremitting condition (particularly if left untreated), I feel it may be one of the most insidious mind-body conditions that can impact the body and lead to major health consequences.  In fact, the long term effects of GAD may be more treacherous and complicated from the standpoint of disease states and associated medical problems than what we have realized or considered in the past (Chrousos & Gold1998).  Research is just beginning to uncover the potential negative implications as we learn more and more about the relationships, processes, interactions, and mechanisms involved (National Institutes of Health, 2003).  

With generalized anxiety disorder, it is argued that because the psychological mind is in a constant state of anxiety, the physical body stays in a constant threat mode as it responds with biochemical and physiological responses to protect itself from the perceived threat.  In other words, anxiety is basically a fear response which elicits the body’s stress response, commonly known as the flight or fight response.  To cope with the threat, the sympathetic nervous system is alerted, and sends out certain chemicals throughout the body to prepare for protection (Barlow, 1988).  Briefly, the hypothalamus is activated and sends chemicals to the pituitary gland to release certain hormones (Glaser, Anderson, & Anderson, 1992). This stimulates the adrenal glands which start producing adrenaline, noradrenaline, and cortisol. Other chemicals involved with stress include serotonin, gamma-aminobutyric acid (GABA), and cholecystokinin (Glaser, Anderson, & Anderson, 1992) The combinations and interactions of this constant influx of chemicals becomes excessive and, essentially, toxic to the body, resulting in unhealthy fluctuations of heart rate, glucose levels, cholesterol, blood pressure, fatty acids, and immune response which are all potential risk factors for disease and may contribute to major health problems. (Chrousos & Gold1998).  Numerous studies have already shown an association between stress and heart disease, decreased immune system, premature aging, diabetes, osteoporosis asthma, gastrointestinal disease, stroke, and even cancer (Anderson, Kiecolt-Glaser, & Glaser, 1994; Barger & Sydeman, 2005; Glaser, Anderson, & Anderson, 1992; National Institutes of Health, 2003; Quigley, 2002).  

In my view, there is a fine line between psychological states, physiological processes, and their interactions.  Does one necessarily precede the other?  Do the mind’s thoughts initiate chemical/physiological changes or do chemical, physiological processes, and their interactions affect our thoughts? What role does nature and nurture play? Is the dysfunction a learned behavior, a chemical/physical process, genetic, or a combination of these and other influences?   Can we truly separate the interactions and processes of mind and body?  These are questions from which researchers must continue to seek answers and I raise them because I believe they are vital to a discussion that is centered on implementing a psychological intervention for a mind –body problem.  The more we understand about the processes and mechanisms involved in stress and stress-related disorders, the better we can devise more effective and appropriate treatment modalities.

An important consideration for me in choosing a therapeutic intervention for a person with generalized anxiety disorder, or any stress-related disorder for that matter, would be based on the evaluation of how the anxiety/stress is particularly influencing and impacting the individual person. This includes investigating the nature of and basis for the stress, as well as, how the individual’s attitudes, beliefs, and values influence the perceived (real or imagined) stress. Furthermore, it is important to remain aware that there are individual differences in the biology of stress as well as interactions between stress and behavioral risk factors for disease. It is also imperative not to try to fit a disorder into a generic treatment intervention.  Each condition is unique and the treatment approach must be appropriate and tailored to compliment the disorder/disease. Other considerations for selecting a treatment model include the client’s culture, ethnicity, socioeconomic background, gender, age, educational level, client time availability, and the individual’s cognitive capacity to participate in the therapeutic intervention.  Clinicians must also anticipate and screen for existing comorbid disorders; it is estimated that at least 25% of individuals with GAD have a co-existing mood or anxiety disorder. 

The reason I chose CBT for GAD is that studies have shown positive results for use with GAD and other anxiety related disorders as well as for mood disorders (Durham,  Chambers,  Power, Major, 2003)  Also, it is currently recognized by as the psychological treatment of choice along with pharmacological therapy (National Institute of Mental Health, 2006).  Some research has suggested that CBT offers a greater sense of personal satisfaction in overcoming the disorder and is even more effective than medication Bassett, 2006).  However, as maintained earlier, individual differences have to be included in this process and clinicians must be cognizant of the individual’s unique psychological, genetic, environmental, and physiological factors involved. However, because CBT has such a broad range of therapeutic modalities within the scope of its theoretical model, I feel it is the best choice for bringing about a positive change in a client with GAD and other anxiety related mind-body disorders.

Cognitive-behavioral therapy basically examines distortions in our thinking and the way we look at our environment and ourselves (Durham, Chambers, Power, & Major (2003). Since negative thoughts usually lead to negative emotions, the goal of CBT is to help the client change (re-evaluate) the negative thoughts before they lead to further psychological and physical problems.  Therefore, CBT is based on retraining the way one thinks.  Automatic negative thoughts are identified and challenged as to their true validity for negative outcomes.  It doesn’t matter so much about the actual severity of the stressor, but rather the perception of the stressor by the individual.  According to Vogel (1985), the biochemical, physiological and/or pathological changes that occur do not appear to be caused by the aversive or threatening nature of the situation itself, but rather by the ability or inability of the individual to cope or deal the perceived problem.  Because perception appears to be a major influence with regard to causing the dysfunctional biochemical reaction, therapy that involves helping one to think differently would seem appropriate.   

CBT aims to help clients learn how to identify, target, and challenge maladaptive thoughts, unreasonable ideas, and irrational belief systems. Once this is accomplished, the clinician can then help the client learn to replace those beliefs with more logical, realistic thoughts, and teaches/ provides positive alternative methods of coping and dealing with ordinary life-provoking problems. Thoughts and beliefs are considered hypothesis that can be questioned and tested.  The client is taught how to gather objective information and examine it.  Once a belief has been identified as maladaptive or irrational, the client is then able to modify his or her thoughts to better conform to the actual reality of the situation.  An increased understanding of the nature, cause, and source of one’s anxiety encourages a more accepting and proactive response to it.  CBT has shown to be helpful in reducing stress levels and helping clients to find alternative ways to confront their feelings of anxiety to enable them to cope better and gain more control over their attitudes, beliefs, and ultimately their feelings (Borkovec, Newman, Pincus, & Lytle, 2002).

Behavioral interventions are also involved in CBT and work hand in hand with the cognitive retraining. Therapeutic interventions include activities such as progressive muscle relaxation, guided imagery, controlled breathing, and biofeedback, for help with calming the body during periods of anxiety (Stanley, Hopko, Diefenbach, Bourland, Rodriguez, & Wagener. 2003).  These techniques can be employed as part of the overall anxiety-reducing approach, depending on the appropriateness of the intervention to the problem and according to the particular individual’s needs/goals. I find it is best to try to implement existing positive aspects of the person’s life, rather than to try to introduce unfamiliar activities.  It is usually enough of an effort in the beginning for the person to start challenging their own belief system without adding further unfamiliar and uncomfortable homework/practices. For example, perhaps the person would be more interested in participating in yoga, Tai chi, meditation, prayer, or other personal relaxation activities.  The proces should not be overwhelming. Goals can be set and taken one step at a time, again, depending on the client.

In addition, because thoughts and feelings often present as habitual or unhealthy behavioral responses, other behavioral techniques may need to be employed when maladaptive behaviors are a result of the person’s anxiety and contributory to an unhealthy lifestyle. Behaviors such as smoking, excess drinking, poor dietary habits, drug abuse, and sedentary lifestyle all factors that play a comprehensive role in the healthy mind-body objective. Therefore, helping the individual recognize these maladaptive behaviors and unhealthy practices will aid in helping them to search for and find alternative activities that will compliment their cognitive progress. The behavioral relaxation techniques mentioned above can be utilized as well as other activates that include humor, reading, gardening, owning a pet, involvement in sports, walking, nature, and creative expression such as journaling or painting.  Through a goal oriented, client centered, and interactive therapist client relationship, appropriate avenues will be uncovered that will allow the individual to challenge the maladaptive thoughts, change thinking patterns, and participate in healthy behaviors while extinguishing the maladaptive behaviors. The outcome will hopefully produce a more balanced, reasonable perspective of oneself, other people, and the environment, resulting in more positive emotional reactions and behaviors for long term results of a healthier mind- body relationship and improved quality of life.

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