CBT involves challenging distorted thoughts and helping patients change maladaptive behaviors. Cognitive-behavioral therapists work with patients to address their maladaptive thoughts in each phase of the disorder. In Priya’s case, treatment would address her maladaptive thoughts—specifically, her worries. Treatment would include the therapist monitoring Priya’s irrational beliefs and trying to come up with rational responses to these beliefs. Modern treatment for GAD might also incorporate mindfulness techniques to help Priya focus on the present moment.
The cognitive-behavioral perspective proposes that psychologists can best understand abnormal functioning by looking at thinking (cognitive) processes and the associated maladaptive actions that people do (behaviors). The cognitive-behavioral perspective holds that abnormal functioning and behaviors result from the person’s maladaptive, irrational, and inaccurate thoughts about and interpretation of a situation. Cognitive-behavioral theorists and therapists believe that by substituting more realistic, rational thoughts for these irrational ones—and by encouraging more adaptive behaviors—clients can change their outlook on life and thus improve their symptoms.
When these individuals hold negative beliefs about worrying, they come to believe that their repeated worrying is mentally and physically harmful and uncontrollable. That causes them to worry further about the fact that they always seem to be worrying. Their meta-worries may include concerns that they are “going crazy” with worry or are losing out on life because of worrying.
Occurrence of repeated obsessions, compulsions, or both. The obsessions or compulsions take up considerable time. Significant distress or impairment. (Information from: APA, 2013)
Free-floating anxiety is used to describe the anxiety and worry about everything and anything experienced by people with GAD.
Reaction formation is a defense mechanism.
This term means “fear of everything.”
Neurosis is an old term for anxiety.
Defense mechanisms are protective strategies our minds develop in order to keep us from experiencing primal thoughts that might be considered unacceptable in society.
The biological Perspective adopts a medical, disease perspective on psychological disorders. According to the biological perspective, disorders such as generalized anxiety disorder (GAD) are brought about by malfunctioning parts of the organism. Typically, the biological perspective focuses on genetic predispositions for disorders and abnormalities in brain anatomy or chemistry. The biological perspective argues that in order to treat psychological disorders, abnormalities in the brain must be addressed through medication or other treatments that act on brain chemistry or circuits.
The cognitive perspective proposes that we can best understand abnormal functioning by looking at cognitive (thinking) processes. The cognitive perspective holds that abnormal functioning results from the person’s maladaptive, irrational and inaccurate thoughts about and interpretation of a situation. Cognitive theorists and therapists believe that by substituting more realistic, rational thoughts for these irrational ones, clients can change their outlook on life and thus improve their symptoms.
The psychodynamic perspective argues that abnormality is largely determined by early childhood experiences navigating stages of development focused around erogenous zones: oral, anal, phallic, latent, and genital. In particular, psychodynamic theorists argue that if children do not navigate these stages properly due to a poor relationship with the primary parental figures in the child’s life, they will experience abnormality as an adult. Psychodynamic therapists would focus on uncovering repressed memories of negative experiences or uncovering repressed feelings.
The humanistic perspective believes in the inherent worth of every individual and that all people have the capacity to strive towards bettering themselves. Those who endorse the humanistic perspective argue that psychological disorders occur when people encounter “conditions of worth” in their lives—unrealistic expectations that others create as conditions that must be met in order to gain love and respect. To counteract this problem, humanist or client-centered theorists and therapists focus on creating a supportive, genuine environment in which the therapist offers unconditional positive regard—that is, support no matter what the client does.
A conversational treatment used by psychodynamic therapists that includes techniques such as free association, or letting the client talk about whatever comes to mind, and therapist interpretation, which involves giving insight and offering an opinion on patterns noticed in the client’s free association and other indicators such as dreams. A psychoanalyst would treat Priya by seeing her 3–5 times per week for several years. Psychoanalysis is costly, and it requires a large time commitment.
Interpersonal therapy focuses on problems in significant relationships in the patient’s life. Interpersonal therapists treat patients by focusing on their current relationships with the most important people in their lives. These people include partners and spouses, parents, roommates, and children. For Priya, this may be her mother or father.
Medication involves taking a chemical agent prescribed by a medical doctor to alter brain chemistry, which subsequently alleviates symptoms. A psychiatrist, who has a medical degree (MD), would be able to prescribe clients medication to treat their symptoms of anxiety or depression. In Priya’s case, an anti-anxiety medication, such as an SSRI, might help treat the underlying cause of her anxiety. As Priya’s therapist, you would continue to meet with her regularly to monitor her symptoms and to refer her to a psychiatrist to adjust the dose of her medication as necessary.
CBT involves challenging distorted thoughts and helping patients change maladaptive behaviors. Cognitive-behavioral therapists work with patients to address their maladaptive thoughts in each phase of the disorder. In Priya’s case, treatment would address her maladaptive thoughts, specifically her worries. Treatment would include monitoring her irrational beliefs and trying to come up with rational responses to these beliefs. Modern treatment for GAD might also incorporate mindfulness techniques to help Priya focus on the present moment.
A treatment in which clients are exposed repeatedly and intensively to a feared object or situation and made to see that it is actually harmless.
The humanistic therapy developed by Carl Rogers in which clinicians try to help clients by being accepting, empathizing accurately, and conveying genuineness.
A behavioral treatment that uses relaxation training and a fear hierarchy to help people with anxiety react calmly to the objects or situations they dread.
A system of therapy whose goals are to help clients uncover past traumatic events and the inner conflicts that have resulted from them, settle those conflicts, and resume personal development.
The process in cognitive therapy by which irrational beliefs are replaced by rational ones through challenging the irrational thoughts in session and via homework between sessions.
A behavioral technique that exposes a client to anxiety-arousing thoughts or situations and then prevents the client from performing his or her compulsive acts.
A treatment procedure that teaches people to relax at will using techniques such as breathing or muscle tension and release.
A cognitive therapy developed by Albert Ellis that helps people identify and change the irrational assumptions and thinking that contribute to their psychological disorders.
Taryn A. Myers, PhD, Virginia Wesleyan University
Please note: Clinical Choices allows you to enhance and test your understanding of the disorders and treatments covered in your textbook, in a simulated case study environment. It is not intended to replicate an actual intake interview or therapy session or provide training on therapeutic techniques. Clinical Choices is for educational purposes only and is not intended as a substitute for clinical training.
The receptionist hands you the intake paperwork prior to your interview with your new client, Priya, who self-referred for therapy because her anxiety is interfering with her job performance. Select the button to review the paperwork before you begin the interview.
Psychological Clinic
Intake Paperwork
Client Name: Priya
Age: 33 years old
Gender: Female
Ethnicity: Southeast Asian (Indian)
Occupation: Flight attendant
Current living situation: I live alone
Why are you seeking services at our clinic? I am afraid my anxiety will start to get in the way of my job as a flight attendant.
You will now ask Priya a number of questions you would typically ask during the intake interview. As you conduct the interview with Priya, begin to think about her symptoms, what her diagnosis might be, and later, what type of treatment might be most helpful to her. Select the “play” button to hear Priya’s responses to your questions. To read the transcript for these answers, select the “transcript” button.
“Hi, Priya. It’s nice to meet you. What we are doing today is called an intake interview. I’m going to have you tell me what brought you here today and ask you some questions that I ask everyone who comes to the clinic. This information will tell me how best to help you. This may mean having you continue to see me for therapy at this clinic, or it may involve referring you to another mental health professional or facility. Let’s start. Tell me about what brought you to the clinic today.”
Priya: I’ve thought about coming in before [hesitates]. I just wasn’t ever sure if it was a good idea. But now ... I feel like I’m fighting a losing battle and I’m … [sharp intake of breath] I’m going to get fired! I’m a flight attendant for a major airline. I actually really love my job! It gives me a chance to travel and see new places and meet new people. I like helping the passengers and hearing their stories. I don’t mind the multitasking. I feel like I’m really good at solving problems while I work with the passengers. I like the bustle of the airport. [with pride] I think I’m good at my job, too. I feel like I can manage any crisis that comes up. But over the past, I don’t know … [tries to remember] year or so… I’ve been missing work – a LOT of work … [sighs] because I feel anxious about flying. That’s not a good problem to have in my line of work, obviously. I sit and think over and over about all the possible things that could go wrong. I just feel really tense all over and super anxious – almost panicky – and then I can’t bring myself to go to work.
Based on her initial report of her symptoms, which of the following anxiety disorders could Priya be suffering from? Select all that are possible diagnoses for Priya. To review the diagnostic criteria for each disorder, select the disorder name.
Priya talked about feeling anxious and panicky about flying, as well as thinking over and over again about bad things that could happen.
“That sounds really difficult, especially in light of your line of work. Missing work must be frustrating for you. Has your anxiety been affecting your life in other ways?”
Priya: I am very anxious about staying in hotels in different cities. I’m starting to wonder if this is the right career for me. I used to be able to calm down once I got to work. But now I find myself worrying about terrorist attacks or a plane crash. But … all this anxiety makes sense, right? It is actually dangerous to fly – we could crash! And something could happen to me while I’m staying in a strange city. We always arrive so late at night, and some of those cities have very high crime rates. As a single woman, it’s just not safe to be out at that time of night … you know what I mean? … Even as I was sitting in your waiting room I was wondering whether I should even be here. After all, everyone has some anxiety, right? Then I was worried you might think I’m crazy for even coming … [pauses] … or the opposite, that I’m beyond help and there’s nothing you or I can do. I find myself thinking about everything that could go wrong … all these possibilities … just play over and over in my mind. I can’t stop worrying …Then, I’m exhausted and I can’t sleep, and that’s when I call in sick to work … I worry I won’t be able to do my job well because I’m sleep deprived. I’m worried that my co-workers will think I’m not pulling my weight or that I’ll snap at them because I’m so tired.
Think about the definition of “meta-worry.” If necessary, select the term to remind yourself of its meaning.
“It sounds like you might be experiencing what we call “rumination”—dwelling on thoughts and thinking about the same things over and over again. It must feel overwhelming, and it’s very common among people who experience anxiety. When did you first start feeling anxious about flying and other things?”
Priya: There have just been so many crashes and mishaps in recent years. Every time I hear about one, I keep thinking, “I could be on the next plane that goes down! This is just one more sign that the world is not safe at all.” You would think that we would not see air disasters like these … especially after 9-11 … and yet … After those crashes, I get sick with worry every time I fly. [pauses] … I worry that I will miss the bus to the airport and be late for work [feels the need to explain] – I take the bus because I don’t drive. I never wanted to drive – I find it incredibly scary. My father made me take Driver’s Ed when I was 16, but then I had two accidents in my first 6 months of driving … so I quit. Driving is too dangerous. I got into accidents even when I was being perfectly safe! I feel like I used up all my good luck with those accidents, so I’ve never driven again, but I still worry about my parents or siblings getting killed in a car crash. But my biggest worry is really flying … I worry I’ll panic on the airplane and then the pilots will have to make an emergency landing, which would upset the passengers. It would be completely embarrassing.
“You mentioned being worried about panicking on a flight. Have you ever actually experienced what is called a panic attack, where you unexpectedly felt very anxious or fearful out of the blue, with physical symptoms like dizziness or chest pain?”
Priya: Yes, definitely! It’s so scary! I feel like I’m going to have a heart attack or die. [reflecting] … I guess I’ve had a few in my life. I have Xanax I can take if I have one, so I carry it with me everywhere I go. I haven’t had an attack in probably like 2 years, though.
Review the criteria for panic disorder and decide whether what is happening to Priya meets the criteria.
“Let’s talk a bit about your childhood. What was it like growing up in your family?”
Priya: Pretty normal, I guess. My parents were married and had four of us – I was the baby. We lived in a normal, average-sized town in Ohio. My dad was kind of distant, hard to impress. I would try to do well in school to impress him, but he never noticed. He worked long hours and when he was home, he had to take my mom out to do errands because she was afraid to go out alone. She was “sick” a lot, and she only ever left the house with dad. Now that I’m older, I wonder if she might have had some kind of phobia. She kept telling me that the world was a dangerous place and warned me about all the horrible things that could happen if you are not on your guard at all times. I wasn’t allowed to play outside unless my mom or dad was there watching me, which made it hard to make friends. [pauses] … I always felt like I didn’t really fit in with my siblings. My brothers are the two oldest, and we got along fine, but they felt like two more dads more than anything else. My sister is 3 years older, and we weren’t really very close … we are so different – different personalities, different ways of looking at the world. My sister never worries about anything and lives one day at a time. She always made me feel inadequate, because she did really well at everything she tried … spur of the moment … no planning … just like that! She never understood why I was always thinking about the future. [sadly] I felt like she looked down on me for it.
How could Priya’s childhood have influenced what Priya is experiencing now? More than one answer could be correct. Select all that apply.
Think about how the behavior of the most significant people in Priya’s life may have influenced her.
“It sounds like you actually started to feel anxious as a child, long before you developed a fear of flying. Do you remember when you first started feeling anxious as a child?”
Priya: Come to think about it, as far back as I can remember I’ve always been a worrier. My brothers and sister used to call me a “worry wart” growing up. When I was little, I used to go around the house unplugging all the appliances before bed because I was afraid of a fire starting overnight. … I remember hearing about how smoking causes lung cancer, and then I was afraid my mom would die because she was a smoker and that all the rest of us would die from secondhand smoke. Even after my mom quit, I still worried about getting cancer.
“Many people who worry a lot struggle with interpersonal relationships because they find themselves worrying about whether they can trust the people in their lives. Has this been your experience?”
Priya: Come to think of it … I guess I do have some problems with trust. I just don’t know when it is safe to trust someone. About 4 years ago, I started dating someone I really felt close to. He was a pilot, so he “got” me – he understood my anxiety about flying and being in new cities. We had been going out for two years when the airline transferred me to Seattle. That made me very anxious because I’d never lived anywhere but Ohio before that. But my boyfriend said he would move with me, so I felt better about the transfer … excited even … We picked out an apartment together, and I flew out there and was setting it up when he called and told me he wasn’t coming. [sadly] He said he “wanted some time apart.” I had a severe panic attack – this is actually the last one I had, two years ago – and I spent my first night in Seattle in the E.R. What a way to start off in a new city, huh? I haven’t dated anyone seriously since. I now live in that apartment we picked out together, and I’m terrified of it being broken into. I have the same worries at home now that I have when I’m travelling. I even keep a pair of men’s sneakers and a large dog bowl outside my front door, even though I’m single and don’t have any pets.
Think what happened to Priya immediately after she moved to Seattle.
“Priya, I sometimes like to end my interviews, especially with clients like yourself who are very anxious, by asking if you have any concerns or questions about therapy. Are there any questions I can answer for you, or are there any concerns you have?”
Priya: Like I said at the beginning of the session … I’m not sure I made the right decision. One of the reasons I’ve never tried therapy before is that although it’s really obvious that all this anxiety is interfering with my life, I [slightly embarrassed] … this is going to sound really weird … I kind of don’t want to give it up! I’m worried about not worrying, as silly as that sounds. Worrying about my safety and staying on my guard has kept me safe! People, in general, aren’t concerned enough about their personal safety and that is why they end up in dangerous situations. I also feel like if I worry, it prevents something bad from happening. You might dismiss this as superstition. But it really works! For example, I got my mom to quit smoking – she quit because she saw how worried and stressed I was about it. Because I kept worrying, she never started up again and she never got lung cancer. [sighs] But it’s exhausting. I can’t relax on my days off because I spend the entire time worrying about my next flight. I worry all the time about everything. I worry about things most other people see as silly – like whether I’ll be caught in the rain without an umbrella, if I can pay my bills on time, if the bus will break down on the way to work. I’ve been able to keep my anxiety under control for a long time, but now I just can’t anymore. So I’m hoping therapy can help me, but I’m worried that it won’t.
Which of the following symptoms is Priya currently experiencing? Select all that apply.
Think about what Priya told you throughout the interview, or go back and listen to the interview again to review her symptoms.
From the File. You remember a former patient who experienced symptoms similar to Priya’s. You review this case to help you diagnose Priya.
[MUSIC PLAYING]
WOMAN: I would worry about things. I'd be concerned about things. And I was just stuck. My tires were spinning and I wasn't getting anywhere. Those worries really kind of took on a life of their own. Things that would be a minor stressor for someone would really, really affect me and I couldn't get over it.
It was more like just a prisoner to these worries and these thoughts. And I didn't necessarily know to give it a name, that it was an anxiety disorder. That I was struggling with anxiety. That there was something that could be done about it.
I thought that was just life and how life was, and I just wasn't as good at coping with it as other people. You get stuck. The worry takes over. You're a prisoner to the worry.
It's hard to even have a conversation with someone about anything other than what you're worried about. It really just comes in like a poison and just takes over everything.
Think about the fact that Priya worries about a lot of the aspects of her life.
Review the checklist for GAD.
In making your choice, think about which perspective focuses on problems that arise from trying to keep certain thoughts out of conscious awareness.
In making your choice, think about which type of therapy focuses on how individuals may be ruled by rumination—that is, by experiencing the same thoughts over and over again.
EPILOGUE
As the therapist, your background is cognitive-behavioral therapy. You assign Priya a thought record worksheet in which to document her irrational beliefs—worries—and you encourage her to refer to this worksheet to begin challenging her beliefs with more rational ways of thinking. At first, Priya struggles with challenging her irrational thoughts, but because she enjoys thinking about things in a rational, logical way she finds that she looks forward to completing her “homework” and she becomes quite good at it.
You also incorporate mindfulness techniques into Priya’s therapy to help her focus on the present moment instead of getting wrapped up in worrying about the future. At first, she is resistant to mindfulness, finding it “weird,” but once you present it as an experiment to be tested, she finds that it is helpful and relaxing, and she stops missing work. Even if Priya does sometimes worry at work, she recognizes that these are irrational thoughts and she can challenge them on the spot. She also uses her mindfulness techniques during takeoff and landing to help her avoid thinking the worst will happen. Although Priya has yet to find a serious boyfriend, she feels ready to start dating again and feels more open to trusting someone in the future.
Real World Application
Increasingly, psychologists are trying to harness the power and accessibility of technology to help their clients. Watch the following video about a smartphone app that has been developed to address anxiety, then answer the questions that follow.
DR. TRACY DENNIS: We did a dosage study. So we had people come into the lab for a single session. And they played either a long dosage, so to speak, of the app, or a short dosage. The short dosage was about 25 minutes, and the long dosage was 40 or 45 minutes.
There we go.
So with this game we've developed, it's a very simple technique where we've taken a lab-based approach and embedded it in the structure of the game. And you basically create competition for attention. And what competes for attention is something negative and something positive.
In our game, we have an anger sprite and a happy sprite. And in the game, what we do is we train people to pay attention to the happy sprite-- to follow the joy, to focus on the positive-- by always following the trail in the grass that the happy sprite makes after the happy sprite burrows down. And what we found is that even with the short dosage, you actually saw reductions in subjective feelings of anxiety after playing the app compared to a placebo control. So it was the exact same game, except you randomly followed the happy or the angry sprite.
DR. SCOTT BEA: I think we need a little bit more evidence. I think we have to actually test this with clinical populations a little bit more characteristically. But I can absolutely see how this could work with a wide range of conditions that we're treating every day.
DR. TRACY DENNIS: We developed this game because there's really a crisis in mental health now, where we have some excellent, scientifically supported treatment for things like stress and anxiety disorders. But they're burdensome. They're expensive.
They're time-consuming. They're stigmatizing. And they're not accessible for many people. So we as psychologists need to do a better job of developing treatments that people can access, that are effective, and really give people a sense of empowerment to promote their own mental wellness.
Think about recent changes in the world today, such as tensions surrounding racism and immigration; the ongoing and pervasive global war on terror; disease outbreaks; natural disasters; crime rates, including mass shootings; and the journalistic focus on crime reporting, economic uncertainty, and volatility. Think about how these aspects of culture may relate to anxiety disorders, giving special consideration to the following:
- That anxiety disorders are the most common kind of disorder
- That 15 percent of people will have some type of anxiety disorder in their lifetime