Icebreaker exercise: What is WORRY?

Brief small group discussion What do you think exemplifies worry? What is it?

Share a definition and/or a description of the phenomenon

When does it happen? Is it normal/abnormal?

Is health anxiety similar and/or dissimilar to generalized anxiety? Is worry different as occurring within somatoform disorders compared to worry within anxiety disorders?

Clinical implications of somatoform? Look in the DSM at somatoform

Flavors?

Discuss reactions with larger group

Health Anxiety and Generalized Anxiety: Comparative definitions

Health Anxiety

Generalized Anxiety

Somatoform Disorder Health-related fears / beliefs, based on misinterpretations of bodily signs and symptoms (indicative of serious illness) Vague to specific

Anxiety Disorder Pervasive, strong worry in anticipation of future possible problems Worries about a variety of topics which can be vague to specific

theres something wrong vs. Ive got cancer

something might happen vs. Ill be fired / evicted / dumped

Significant distress and functional impairment Not helped by medical reassurance

Checking / safety behaviors Avoidance of triggers

Problem is not in the present so worry is a skewed attempt at problem-solving for the possible future danger / threat Frequent safety / avoidance behaviors

Key aspect: Intolerance for uncertainty

Key aspect: Intolerance for uncertainty

Health Anxiety & Generalized Anxiety: Features

Generalized Anxiety

Health Anxiety

Lifetime prevalence: 1 4.5% Women higher risk

Report more physical symptoms than do men Gender differences disappear between truly sick people Self Family (significant other)

Onset common after illness

Begin in early adulthood Reluctant to view other causes than physical

Lifetime prevalence: 6 - 9% Women higher risk (2.5X) Risk also higher for young adults and African-Americans Onset gradual Begin in childhood 25 year duration is average when treatment is sought Treatment typically sought for another reason Tension is only GAD unique Sx

Will more commonly present to PCP or specialist for tests and somatic / physical treatments

Higher rates in 45+ Many have an Axis I anxiety and/or mood disorder

Restlessness, keyed up, on edge Easily fatigued Difficulty concentrating Irritability Muscle tension Difficulty sleeping

25% will develop Panic Disorder Somatization disorder also common

90% will develop another Axis I disorder

Panic: Bimodal distribution in age onset with peaks 15 24 and 45 54

42% will develop MDD or Dysthymic Disorder Avoidant Dependent Obsessive-compulsive

Axis II up to 50% may meet criteria

Hormonal changes during these periods

Health Anxiety & Generalized Anxiety: Poor prognostic indicators

Historically, the majority of patients report unremitting courses of illness because they are likely to detect potential threat through hypervigilant states, which then cues their worry (self-feeding cycle) Intolerance for uncertainty (IU) now appears to be a central mechanism of pathology which sustains both Health Anxiety and Generalized Anxiety

IU leads to engaging in mental problem-solving in (ambiguous) situations when outcomes are uncertain

Overestimation of negative events / probability / cost estimates Underestimation of coping capacity / help & assistance estimates

Worry is a maladaptive attempt to cope

Ineffective in threat reduction and problem-solving Negatively correlated with all sorts of pathology Different from conceptual planning and preparatory coping

Cognitive-Behavior Therapy & Anxiety Disorders

By the late 1980s, effective CBT interventions were in place for many of the more common anxiety disorders Treated with specific CBT methods, targeting specific mechanisms of the various disorders GAD was still treated with broad-based anxiety reduction techniques

Effective to some extent

Relaxation + biofeedback (d = .34) Relaxation + functional analysis (d = .51) CT + relaxation (d = .64) CT alone (d = .59)

Residual worry and anxiety & high relapse rates remained common

GAD remained a therapeutic enigma HA faired even worse, sometimes labeled psychosis or delusional

French Canadian Model of Worry & Uncertainty

Researchers in French Canada are currently proposing intolerance for uncertainty as a driving mechanism for worry (Ladoucer, Gosselin, Dugas) IU may indeed be a basic ingredient to several anxiety disorders New model has produced early, promising results for GAD Can it be applied to other, worrybased disorders?

Intolerance for Uncertainty

Definition: The tendency to react negatively on an emotional, cognitive, and behavioral level to uncertain situations and events Specifically: These patients find ambiguity stressful and upsetting, and have difficulty functioning in uncertain situations

They believe that uncertainty is negative and should be avoided, and that being uncertain is unfair

Reality: Everyday life is filled with uncertainty, giving these patients ample, regular opportunities to worry

Even when things are going well, they worry things will change for the worse

Health Anxiety: A basic cognitive understanding

Combinations of cognitive errors Overestimation of probability Overestimation of severity Overestimation of just how intolerable it would be Underestimation of own capacity to cope Underestimation of actual, real help available

Probability estimation: A common problem for anxiety disordered individuals

Specific CBT treatment for GAD

Helps patients recognize, accept, and develop strategies for dealing with uncertainty in environment Teaches patients to distinguish between two types of worry (current vs. potential problems), and to apply different strategies for each kind Reevaluating the usefulness of worry, and developing sound problem-solving strategies for worries about current problems and using cognitive exposure for worries about potential problems Each component aims at increasing tolerance for uncertainty, and can be adapted and modified to fit HA-specific instances of worry

usefulness of worry & effective problem orientation

GAD Model unfolding: See patient manual

Imaginal exposure: Keeping it terrible!

CBT overall d = .70; CBT + imaginal exposure d =.91

The case of John

John (pseudonym) 36-year-old, clinically obese, Caucasian male Suffered with a host of intense illness worries since 1990 Misinterpreted:

Arm pain / chest pain = heart attack Head ache / sinus ache = stroke / brain tumor Stomach upset / bowel distress = stomach / colon cancer Persistent checking, reassurance seeking, avoidance (of health-related thoughts / images, and physical exertion) High medical utilization, persistent (resistant) fear, impact on personal, social, professional life, and real health problems

Result:

Net effect:

The scientific method: Apply the experimental GAD treatment model to HA

Hypothesis: As HA is, conceptually at least, a more narrowed form of worry (worry w / a more exclusive health focus), it should respond favorably to the new French-Canadian model for GAD

Presumes that central variable / mechanism to both conditions is intolerance for uncertainty

Test: Apply the new treatment model to John, measure progress and longer-term outcome and compare findings from treatment against existing HA treatment outcome literature If John responds well to treatment, can further conceptual lines of thinking be formed?

e.g., is HA in its foundation GAD, somatic type?

Early outcome findings

Beginning of treatment:

Health-related fears re: heart-attacks, strokes, cancer Low problem-solving skills

Worry, avoidance, and safety behaviors predominant coping style

Ex-consequentia reasoning predominant style

Low accuracy in probability estimation

Low tolerance for health-related stimuli

End of treatment:

d = 2.56

Typical, everyday normal concerns about personal, social, work life Much improved problem-solving capacity Greater accuracy in what physical signals mean, and greatly increased capacity to tolerate distress caused by common ailments

No ER visits during treatment phase, during follow-up, and appropriate use of antibiotics in face of one (1) significant sinus infection

High tolerance for health-related stimuli / decreased focus on such

6-month follow-up:

d = 3.41

Gains made in treatment sustained and additional progress made

IUS at baseline, post-treatment and at the 6-month follow-up.

120 100 80 60 40 20 Baseline Post Follow-up

IUS PSWQ WW

Appropriate worries

Patient data and IUS / WW / PSWQ reliable change indicators

Subject John Duration 14 years #sessions 13 Pre-test IUS: 103 WW: 701 PSWQ: 711 Post-test IUS: 54 * WW: 252 3 * PSWQ: 422 * Follow-up IUS: 382 3 * WW: 282 PSWQ: 302 3 *

Notes:

Score more similar to clinical population. Score more similar to general population. Reliable change observed from prior observation. * Improved functioning change.

Conclusions