6 Kieron O’Connor, Amélie Drolet-Marcoux, Geneviève Larocque and Karolan Gervais Generalized anxiety disorder (GAD) is traditionally considered a residual disorder diagnosed in the absence of criteria for other disorders. In DSM-III-R, GAD became its own category characterized by apprehensive expectation in a limited number of specific worry domains (Watson & Friend, 1969). Core symptoms of GAD include a disarming array of somatic, behavioural and cognitive signs, including both autonomic hyperarousal and hypoarousal, and most reliably muscle tension and worry (Barlow, 2002). Despite strong somatic signs, GAD is considered mainly a cognitive disorder. Research in GAD has therefore focused predominantly on clarifying the nature and function of worry: worry and meta-worry. In worry, the person dwells endlessly and aversively on the future aspects of a problem or event, anticipating negative outcome and an ensuing inability to cope. In meta-worry, people worry about the fact that they worry (Cartwright-Hatton & Wells, 1997). Both meta-worry and worry thought sequences can interact in handicapping real problem solving and increasing anxiety (Mathews, 1990). Worry reduces somatic activation and attempts to control worry may be forms of experiential avoidance that are self-perpetuating and that distract from what would be more effective behavioural forms of responding to the environment (Hayes, Strosahl, & Wilson, 1999). Clinically, treating GAD can lead to a tortuous process where anticipation produces worry, which produces somatic symptoms, which produce further worry and meta-worry about the worry and further anxiety and performance difficulties. In keeping with the diverse nature of the disorder, there are a number of evidence-based standardized treatment packages, mostly cognitive–behavioural therapy, available. These include protocols highlighting imaginal exposure, problem solving (Craske, 1999), programme relaxation (Ost, 1987), cognitive and meta-cognitive restructuring (Wells, 1999), intolerance of uncertainty (Ladouceur et al., 2000), interpersonal processes (Borkovec, Alcaine, & Behar, 2004) and narrative approaches (O’Connor, Gareau, Gaudette, & Robillard, 1999). In this chapter, we illustrate how the vagueness and seeming contradictions of GAD can be overcome by a case formulation approach that centres evaluation and treatment around the person and contextualizes worries within personal and interpersonal domains. We discuss three cases, all of which received an ‘official’ diagnosis of GAD (by structured clinical interview) but required separate and independent case formulations. The GAD symptoms in each case were linked together with an interactive case formulation using individual schemas in collaboration with the person. The schemas allowed progressive targeting of the contents of the worry in a way that was meaningful to the person and allowed them to understand how worry functioned in their life domains. So, the individual case formulations were idiosyncratic and not comparable, despite all three cases sharing a common diagnosis. The three cases also received different treatment modalities, so illustrating how case formulation can lead to tailored treatments. In particular, we moved beyond a matching symptom to technique approach towards a matching person to treatment approach, in order to uncover the individual variation regarding development, presentation and maintenance of the disorder. The complexity of the model is brought together through a personalized rather than standard focus on interlocking behaviours. The principle of this case formulation approach is that though there may be several symptoms, there is only one person and understanding the underlying mechanism in personal terms allows the clinician to pinpoint how problems interact in daily life and so to provide a singular solution. The first client, John, was in his early 30s and living with his common-law spouse and their newborn baby. He was a university-educated civil servant. His presenting complaint was periods of anxiety that he could not link to any particular stressor in his life. John reported that his first such period of intense anxiety had happened 7 years earlier and that he had had regular episodes since then. His objective was to experience less of the thoughts and have more ‘control of my thoughts’. The therapist detected a conflict in John’s non-verbal and verbal discomfort of expressing his problem. He was torn between admitting his thoughts and seeking help and protecting himself. The therapist noted that the client was clearly uncomfortable talking about his anxiety, and discussion seemed to make him more anxious. This discomfort had led to abandoning previous therapy. The therapeutic alliance with the therapist was initially tense, largely because John also had some narcissistic traits that led him believe he ought to be able to control his thoughts on his own and that prevented John from accepting therapist suggestions. So he was constantly critical of the therapist, convinced she did not understand his anxiety and would make it worse. As noted, John was very anxious about discussing his anxiety, and his tone was monotone, indicating a desire to avoid emotion, which he felt not only showed control but also presented him as someone correct and superior. Sometimes, the therapist’s suggestions were met by an attacking attitude where John would deny having said or agreed to a plan previously. One hypothesis to account for this behaviour was a dislike for or resistance to the therapist. This hypothesis was dismissed by John’s own account, who reported independently how he liked the therapist. Finally, the therapist realized that John was only half-listening to her due often to absorption in his thoughts and so had not fully understood the formulation. But due to his narcissistic traits and high standards, he could not admit to not understanding. The pace of conversation was slowed to allow time for feedback and understanding. The therapist was also aware of her own reaction to these episodes and consequent dislike of the patient interaction, which she set off by focusing on the behaviour in the context of the patient’s suffering. So the therapist summed up John’s problems as anxiety caused by thoughts John felt he should not have or should be able to control. This anxiety was fuelled further by his narcissistic traits and a perfectionism that heightened his judgement about the admissibility of his thoughts. There was also a lack of understanding of the nature of thought control and of how thoughts work and finally the use of self-sabotaging strategies such as thought suppression that paradoxically increased the intensity of the thoughts. According to John’s description of his principal problem, a negative thought would come to his mind (e.g. ‘I could stop loving my spouse’) and set off a series of further negative thoughts (e.g. ‘I could hurt my spouse or my baby’; ‘I could become so anxious I would be unable to be a good father’ and ‘I would be a failure and go crazy’). John said that these thoughts and the anxiety symptoms that accompanied them (nausea, loss of appetite and sleeping problems) could last several days to a few weeks. The therapist decided to explore exactly what anxiety meant for this client. This deconstruction of anxiety is important in a clinical setting since anxiety is an umbrella term with a different sense to everybody. The therapist established with the client that John’s principal fear was losing control. By identifying a list of possible consequences (death, illness, loss of relationship, becoming non-functional, losing control and going crazy) of his anxiety, the therapist established that for John, losing control meant loss of self and potential mayhem and becoming crazy and non-functional. The therapist began to collaboratively explore with John a general model of his anxiety. In particular, the sequence of thoughts leading to John’s anxiety was unclear. In John’s own words, he would anticipate a negative thought, then anticipate feeling guilty about the thought and consider he was not strong, then wonder if the thought would make him crazy. He was torn between considering he should not have the thought and feeling he should attend to it, so ending up with mental neutralization and avoidance. Since there was no external trigger, the hypothesis was that anticipation of this conflict was the principal trigger. The therapist also evaluated the coping strategies used by John and his attitudes about the usefulness of worrying in general. John answered that he put a moderate amount of effort into controlling his worries. The main strategies he used were trying to distract himself, rationalizing the worry by trying to argue against it and trying not to think of the things that worry him. The main beliefs about worrying endorsed by the client were that worrying creates stress for the body, worrying could do him harm and worrying too much could cause him to lose control. John had developed a series of cognitive avoidance strategies that he used to cope with anxiety. He described how he would avoid things that could trigger negative thoughts (e.g. images of people apparently out of control, as in wild enjoyment, and places (e.g. billboards) where he might see these images). He would seek reassurance from his spouse and friends. The reassurance seeking involved asking questions such as the following: Did I say or do anything wrong? He also practised meditation and took baths to calm himself during periods of extreme anxiety. He also used relaxation techniques regularly in order to reduce, as he put it, his general ‘susceptibility to anxiety’. Most often, John would repeat to himself that his negative thought was ‘unrealistic’, as a form of self-reassurance until he was able to mentally neutralize the thought. So the question in the therapist’s mind was how aware was John of the link between his anxiety and avoidance. In order to make John more aware of the succession of his thoughts, the therapist found it useful to map out in a diagram triggers and how the thought triggers led to more thought triggers and more anxious thoughts and more triggers. A general diagram or schema was elaborated with John (see Figure 6.1) and seemed to show that John maintained his anxiety by anticipating having anxiety-provoking thoughts. He used certain cognitive strategies (mental neutralization and self-monitoring) and behaviours (avoidance, reassurance seeking and relaxation) in order to reduce his anxiety symptoms, but these strategies worked only on a short-term basis. In the long run, they increased his susceptibility to anxiety by augmenting his anticipation through rendering the negative thoughts more salient. (These were treated as if they really were dangerous and must be avoided.) The model also contained personal themes that determined the content of the negative thoughts (his guilt and excessive sense of responsibility) and gave some insight into why these thoughts were salient for John (why he attributed importance to them). So the next task for the therapist was to explore why the content of the thoughts was so important to John. Figure 6.1 General model. This schema shows how John’s anticipation of a negative thought elicited a negative reaction leading to the conflict between feeling he should attend to the thought and that he should not have the thought leading to avoidance. Clearly, an additional factor affecting John’s anxiety was his perfectionism, which interacted with his fear of losing control. In dialogue with John, what appeared at first to be a rigid moral value that he should not have thoughts about not loving his wife turned out not to be morally inspired but rather an expression of his perfectionism that there must always be a ‘correct’ way of acting and he must always be ‘correct’ and never lose control. As the therapist noted to John, and he agreed, the fear of loss of control led onto the further fear that letting a therapist help would also be a sign of him losing control. Involving John in designing the schema collaboratively allowed him to participate in the therapy and in part to feel more ‘in control’. The therapist used an iterative process to elaborate the schema in collaboration with John. Each element of the model and each relationship between elements were proposed as a hypothesis to be accepted or rejected or tested by the client before moving on. John was also invited to add or propose elements and relationships to the model, and his wording was used in the models (see Figures 6.1 and 6.2). Figure 6.2 This schema illustrated how John’s testing behaviour to check he was anxious far from keeping him anxious increased his anxiety, which made him abort his exposure and incubate the anxiety further. John did not remember having anxiety as a child, but he described himself as a shy person during childhood and adolescence. John’s story about losing control came from past experiences where he felt he could lose control of his actions while playing games on the computer and could not stop. He felt he had become addicted to the computer games. John had read about computer addiction and the more he reflected, the more he considered himself at risk. He pointed to sensations that he experienced automatically, like excitement, as proof of his impulsivity. He could not let himself go and have pleasure because of his fear of losing control, and so he monitored his thoughts anxiously. John reported frequently experiences of anxiety when he had pleasure as a child. John recalled one or two examples of family outings where he had enjoyed himself. He had run too quickly for an ice cream and fell and grazed his knees. Later, he had turned over the day increasingly, regretting his lack of discipline. To him, his very childish immaturity seemed a sign of being out of control, compared with his parents’ composure. Although his parents were strict, they were not moralistic, but there seemed religious overtones, where religious examples were often invoked to install sense of worth (e.g. What would Jesus say about that idea?). Actually, John told the therapist he believed in God and had quit smoking as a promise to God, and he now could not let God down. The formulation was elaborated in a series of schema connecting distinct elements contributing to his anxiety. Part of developing the schema was educational wherein connecting up interacting problems John realized how the problems built on one another and what transition points he could address to change the course. Each schema was associated with a therapeutic goal negotiated with John (see below), and John was asked if he recognized his way of functioning in these schemas and if so did he wish to work towards these goals. All three schemas, with their respective goals, are shown (see Figures 6.2, 6.3 and 6.4). Figure 6.3 This schema illustrated to John how his attempts to monitor his loss of control produced a fear of losing control and hence more anxiety. Figure 6.4 This schema illustrates how John’s perfectionist and self-critical tendencies lead to a conflict between enjoying an activity and feeling bad. This activity might lead to enjoyment, losing control and hence transgress his values. This ambivalence in turn led to more self-criticism and anxiety. The schemas were developed with the client by firstly listing all elements of the problem. The therapist worked with John to put these elements into a sequence. So, for example, John would anticipate thinking a thought, feel guilty about the thought and consider he was not strong that he would not be able to stop going crazy and that he would lose control. This sequence allowed both the therapist and John to reflect on the anxiety built up largely through anticipation of feeling anxious and John realized he was torn between wanting to not have the thought and feeling he should however attend to it. It seemed to the therapist that there was also an inner struggle between what John thought and what he thought he should think, which had led to the guilt and avoidant strategies and the constant reassurance seeking. Through the schema, John was able to see how the push and pull dynamic ‘wanting to attend – not wanting to’ also maintained the anxiety. The therapist reflected on whether the anticipation, the conflict or the avoidances was the principal root of the problem. There were several elements to target since his avoidance strategies and his evaluation of his thoughts were both factors maintaining anxiety. The therapist’s plan of action was to break the vicious circle by either dealing with avoidance first or addressing John’s thoughts. But the therapist was unsure which to target. The initial goal was to break the vicious cycle of – anxiety – avoidance – short-term relief – more anxiety – progressively. So it was important to identify the right point of entry to break the cycle. Was it through changing his thoughts or his behaviour? After looking at the sequence with John, it seemed avoidance was the more doable option. The therapist first targeted the elimination of John’s avoidance strategies, and he agreed to gradually stop using them. This target was intended to break the cycle by helping John let go of the notion that he should keep control through avoidance (see Figure 6.1, entrance into the cycle marked by the letter A). John was successful in this first step, in which he gained knowledge of his idiosyncratic ways of avoiding negative thoughts, such as mental neutralization and behavioural avoidance of images and situations where he would anticipate getting anxious. His remark was ‘Yes I see how this works’. John also came to understand that avoiding anxiety-provoking thoughts was in a way, in his words, ‘training his brain to believe that these thoughts are actually dangerous’. The second step of the exercise consisted in identifying the positive significance the client attributed to his negative thoughts (e.g. ‘these thoughts will help me to plan for the worst’) in order to completely dismantle the cognitive mechanism by which John was attributing so much importance to his negative thoughts (see Figure 6.1, section of the cycle marked B). John started this second step of the exercise, but he found it difficult to find occasions to put it into practice as his anxiety had greatly diminished over the first period of treatment as had the frequency of his anxiety-provoking thoughts. Partly as a result of avoiding avoidance and exposing himself to anticipation and the fear of becoming anxious, his anticipation had decreased. John indicated that he feared anxiety itself much less than he did at the beginning of therapy. So the therapist reasoned that the hypothesis about anticipation as the trigger for more anxiety seemed supported. Addressing avoidance strategies by avoiding avoidance was sufficient to eliminate a number of meta-cognitive elements that were maintaining John’s cycle of anxiety since the worst did not occur (‘Anticipating the worst’ was not helpful.) As the client came to understand more fully the rationale behind the intervention (‘anxiety fuels itself by the use of strategies that make anxiety more likely’), he also felt a decrease in his fear of anxiety itself. It became obvious to him that to a certain extent he could simply stop maintaining his own anxiety by modifying his meta-cognitive style. For example, he was sure he had to monitor his anxiety level and even test it out in the presence of anxiety by thinking thoughts to make himself anxious. So a series of behavioural experiments were devised to decide whether not testing out made John feel better or worse. The schema in Figure 6.2 represents how John had developed a habit of testing his level of anxiety by engaging in an anxiety-provoking behaviour and then withdrawing from the activity before his anxiety level could go down (as it would do if he maintained exposure). The therapeutic objective proposed was to avoid increasing anxiety by eliminating this withdrawal. John was able to carry through the task with some anxiogenic thoughts about his future and some pleasant activities like reading adventure stories where he became stimulated. He realized when carrying on instead of withdrawing, he felt better and he did not lose control. The schema in Figure 6.3 represents John’s fear of losing control, as discussed above. The therapist was partly able to work on this fear, using cognitive restructuring techniques to reduce fear of losing control. John would frequently monitor his thoughts and behaviour for any sign of losing control. Unfortunately, this very monitoring made him anxious. He would often go further and test himself by thinking certain thoughts and gauging his reactions. If his reaction was at all ambivalent, he would be anxious. So, for example, he would think, ‘Do I love my wife?’ and then would ruminate if his reaction was correct. In a similar fashion, as soon as he undertook an enjoyable activity, for example, playing games on the computer, he began to fear losing control. Losing control for the client was synonymous with becoming addicted and hence implied inability to inhibit a behaviour. The theme of exerting tight control was explored in several life domains with John. How could one control every aspect of a behaviour? Was it feasible or desirable to control every component of an act? By exerting too much inhibition, could one not impede the flow of an automated act? John agreed to observe how he functioned in everyday life and test the effects of losing control. Was action aided or compromised by his testing and monitoring behaviour? But although John admitted he felt more confident and in control with less testing, he still feared losing control. The therapist was initially puzzled. The irony was that his testing and questioning increased his anxiety and worry, which augmented his belief that he could lose control. Intellectually, John had understood how testing (Figure 6.2) can favour anxiety and was making efforts to abstain from engaging in this habit. The therapist decided to re-emphasize the connection between his beliefs and anxiety. The therapist’s aim in constructing these schemas was to plan treatment specifically to address different elements underpinning John’s anxiety problems that had been uncovered during work on the general model (Figure 6.1). These elements were his habit of anxiety testing (Figure 6.2), his self-monitoring, his fear of losing control (Figure 6.3) and his perfectionism/self-criticism (Figure 6.4). The therapist’s aim was that revealing how the elements contributed jointly to the anxiety would facilitate John’s readiness to work on each one. However, John saw the element addressed in Figure 6.3 (fear of losing control) not so much as a problem but as a protective mechanism helping to avoid having behaviour that he did not want to have. The therapist explained to John that he would be freer, not less free, to choose his behaviours if he got rid of his anxiety (his fear of losing control). But regardless of the outcome of the behavioural experiments, John held on to the belief that his behaviour could become out of control if not monitored. This quandary suggested to the therapist that a deeper strongly held belief was controlling the monitoring. The schema in Figure 6.4 illustrates how John’s perfectionism turned what might have been an acceptable discomfort into full-blown anxiety. Here, the therapist’s aim was to use cognitive restructuring to normalize the fact that John could sometimes be unsure if his way of behaving was absolutely correct (moral or otherwise) and that this kind of discomfort is a common experience. Initially, John considered his problem with the computer and other pastimes was a fear of losing control. But a behavioural experiment with playing a game on his computer for a limited time showed that in the here and now he could not lose control even if he wanted. However, this vigilance about losing control had become a conflict between what he termed values and pleasure. The experimental work on the schema in Figure 6.4 reached an impasse when John changed his mind and no longer accepted that his discomfort came from ambivalence between the conflict between moral values about being correct and having pleasure, which was then magnified into anxiety by a perfectionist attitude. Instead, John insisted that his ambivalence was between the risk of engaging in an activity that on the one hand was pleasurable but on the other hand could provoke anxiety. This new formulation represented a new contradiction for the therapist. John considered that any pleasurable activity, one that was enjoyed too much, could by itself become anxiogenic. Although the fear of losing control was evident here, it was also supplemented by an implicit moral censure about enjoyment. The therapist explored this moral dimension using downward arrow technique. If he enjoyed himself, what did this mean? That he was lazy, irresponsible and sinful even? John realized in his mind there was a fusion between enjoying himself too much and becoming out of control. A fear that enjoying himself too much signalled addiction, which signalled loss of control. The therapist and John devised a behavioural experiment where John would carry on with a very pleasant activity such as playing on the computer until tired and show how any activity tires in the end without loss of control. However, John terminated therapy before his paralyzing reasoning about enjoying and losing control could be put to the test and be fully understood. The therapist tried to clarify with a new model this implicit contradiction fuelling distress in his personal functioning. John managed partial exposure to a number of situations where he was able to immerse himself in activity naturally, but other activities, especially related to more sensual pleasure, where he felt stimulated, even erotic, he felt were forbidden, not for moral reasons but because enjoyment implied implicitly that he might lose control. Although therapist and John agreed that there was more work to be done on his beliefs concerning enjoyment in order to eliminate more fused anxiety-provoking/-maintaining mechanisms, John reported that he was satisfied with the understanding he had gained and with how much his anxiety had been reduced during therapy. In fact, when asked to evaluate the therapeutic process, John expressed a high level of satisfaction in a self-report therapy satisfaction questionnaire. For example, he expressed particular satisfaction with exposure to anxiety-provoking thoughts and becoming aware of the interactions between his thoughts, his thoughts about his thoughts, his emotions and his self-sabotaging behaviour. At 1 month follow-up, John still reported being satisfied with his improvement and feeling confident that he would be able to continue applying what he had learned in therapy. He was able to understand how his anticipation led itself to fear, which was then confounded by his judgement. ‘So I’m going to worry about my wife, I shouldn’t have this thought, what a terrible person I am, this will never end’. He was able to halt this type of sequence through curtailing the chaining. The situations he was better able to cope with included situations where his anticipation immediately increased his fear, where he would normally start ruminating about lack of control and ask reassurance from his wife. For example, reading, talking and everyday life were predictable situations where he was fine. However, browsing the computer was a situation where he could suddenly come across an item or a site and he did not know where it would lead. So, here he still felt he needed to be on guard. Concerning objective measures, the Why Worry questionnaire (Freeston, Rhéaume, k Letarte, Dugas, & Ladouceur, 1994) to understand what motivated his worrying, the Intolerance of Uncertainty scale (Buhr & Dugas, 2002), the Health Anxiety Inventory (Lucock & Morley, 1996), the Beck Anxiety Inventory (Beck & Steer, 1991) and the Multidimensional Perfectionism (Frost, Marten, & Lahart, 1990) scale indicated significant change after treatment, and John reported an increase in life satisfaction as well. The following is an excerpt from a dialogue between John and the therapist where the therapist became aware of how committed John was to self-monitoring and how a core belief can maintain self-sabotaging behaviour, even in the face of the benefits of not maintaining the behaviour. Vignette (T = Therapist; John = J) – John and self-monitoring T:
Generalized Anxiety Disorder
Personalized Case Formulation and Treatment
Introduction
Case 1 – John
Definition of presenting problem
Exploration
Developmental factors
Formulation
Intervention
Outcomes and Evaluation of Therapy
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Generalized Anxiety Disorder
So when you’re on the computer, what are you doing?
