Generalized Anxiety Disorder Workbook

Reference

The Generalized Anxiety Disorder Workbook: A comprehensive CBT guide for coping with uncertainty, worry, and fear, by Dr. Melisa Robichaud & Dr. Michel Dugas (2015: New Harbinger). [Amazon] 

Free online tools that accompany the workbook

About the authors

Melisa Robichaud, PhD, is a clinical psychologist and cofounder of the Vancouver CBT Centre. She holds adjunct clinical faculty and clinical associate positions in psychology and psychiatry at the University of British Columbia and Simon Fraser University. Robichaud specializes in the treatment of anxiety with an emphasis on generalized anxiety disorder (GAD), and is on the scientific advisory board of AnxietyBC. For over a decade, she has provided workshops and training to both mental health professionals and the public on the treatment of GAD, and has published numerous book chapters and scientific articles on the subject. Links to more information: Psychwire

Michel J. Dugas, PhD, is professor of psychology at the Université du Québec en Outaouais, and affiliate professor of psychology at Concordia University. Over the past two decades, he has conducted research on the etiology and treatment of generalized anxiety disorder (GAD) with a specific focus on intolerance of uncertainty. He has published over ninety scientific articles and made more than 250 conference presentations on the topic of GAD. Dugas is a Fellow of the Canadian Psychological Association and the Canadian Association of Cognitive and Behavioural Therapies.

An Overview of The Generalized Anxiety Disorder Workbook

This workbook provides a comprehensive and structured approach to overcoming GAD using the methods of cognitive-behavioral therapy (CBT). Below is an outline of the book.

Chapter 1: Worry, anxiety, and GAD (pp. 5-28)

Assessing whether your worry is problematic (p. 9)

• Worry & Anxiety Questionnaire (pp. 15-17)

• Worry Monitoring Log (pp. 21-24)

• (Also see: GAD Assessment)

Two types of worry: worries about current problems versus worries about hypothetical situations (pp.25-28)

• Worries about current problems involve concerns about problematic situations you are dealing with in the here and now, for which you may be able to do something about. Example: I am having a hard time finishing an assignment for school or work. What if I don't get it done on time?

• Worries about hypothetical situations involve things that haven't happened yet, and may never happen. They often involve situations in the distant future that you have little to no control over. Examples: "What if my plane crashes? "What if someone in my family dies and I can't cope?"

Note: These two different types of worry require a different kind of response. Chapter 9 presents a structured problem-solving approach for current problems. Chapter 10 provides guidance on how to use exposure therapy for hypothetical worries.

Chapter 2: CBT for GAD (pp. 28-50)

The relationship between thoughts, emotions, and behavior

What CBT focuses on changing: Thoughts and behavior

The nature of CBT

Chapter 3: Is worry helpful? (pp. 51-70)

Note: Chapters 3 and 4 concern positive beliefs about worry

Common positive beliefs about the usefulness of worry: 

• Worry is a positive personality trait

• Worry helps with problem-solving

• Worry provides motivation

• Worry provides protection from negative emotions

• Worry can prevent negative outcomes

Exercise 3.2: Identifying your positive beliefs about worry (pp. 59-61)

Exercise 3.3: Addressing ambivalence about change (gains and losses if I worry less)

Exercise 3.4: Thinking about a life without worry

Chapter 4: Positive beliefs about worry - Examining the evidence (pp. 71-102)

Exercise 4.1: Examining "Helpful" worries and positive beliefs

Evidence for and against the value of worrying

Exercise 4.2 (pp. 78-84): Building a Defense for Your Worries - Evidence That My Worry Is Useful

Exercise 4.3 (pp. 84-89): Building a Case Against Your Worries - Evidence That My Worry Is Unhelpful

Weighing the evidence

Exercise 4.4 (pp. 91-93): Finding paradoxes within the evidence

Exercise 4.5 (pp. 93-97): Weighing the pros and cons

Exercise: 4.6 (pp. 97-): Reaching your own verdict

Chapter 5: Worry and the threat of uncertainty (pp. 103-115)

Note: Chapters 5-8 concern intolerance of uncertainty.

Metaphor: An allergy to uncertainty

Worry is triggered by three situations: Unpredictable situations; novel situations; ambiguous situations

Beliefs about uncertainty: It is unfair to feel uncertain; uncertain events will turn out negatively; I won't be able to cope with unexpected negative outcomes. 

Exercise 5.1: Tracking types of triggers and beliefs

Chapter 6: Intolerance of uncertainty in action: Identifying safety behaviors (pp. 116-131)

Safety behaviors revolve around reducing, avoiding, or eliminating uncertainty

GAD safety behaviors: 

• Approach strategies: Excessive reassurance seeking; double checking; excessive information seeking; excessive list making; doing everything yourself; doing things for others

• Avoidance strategies: Avoidance; procrastination; partial committment; impulsive decision-making

Exercise 6.1: Identifying your safety behaviors (Safety Behavior Monitoring Form) (pp. 125-127)

Chapter 7: Tolerating uncertainty: Testing out beliefs about uncertainty (pp. 133-147)

Prior to beginning this chapter, complete Exercise 6.1: Identifying your safety behaviors (Safety Behavior Monitoring Form).

Behavioral experiments allow you to directly test beliefs by predicting what you think will happen in a situation, deliberately entering that situation, refraining from using safety behaviors, and then finding out what really happens.

Experiments allow you to test the following beliefs about uncertainty: Did the uncertain element in this situation lead to a negative outcome? If a negative outcome occurred, how bad was it? If a negative outcome occurred, how did you cope?

Developing your own behavioral experiments (pp. 137-138)

Tips for conducting behavioral experiments: Start small; expect to be anxious; repeat an experiment more than once

Exercise 7.1: Testing out negative beliefs about uncertainty (pp. 141-142)

Troubleshooting behavioral experiments: Difficulty coming up with experiments; not experiencing anxiety; not being motivated to do the experiments; not being able to follow through without using safety behaviors.

Chapter 8: Moving toward embracing uncertainty (pp. 149)

Diversifying your behavioral experiences; raising the stakes in yur behavioral experiments

Exercise 8.2: Developing more challenging behavioral experiments

Tailoring your experiments to specific fears: Loss of control; fear of making a mistake

Exercise 8.3: Making behavioral experiments an ongoing process

Finding the positives in uncertainty

Chapter 9: Coping with worries about current problems (pp. 167-)

Exercise 9.1: Monitoring worry types (and focusing on current problems)

Understanding problem-solving: There is a difference between worrying about a problem and actually solving them.

Problem-solving is comprised of two components: Yoour orientation to problem solving, and your actual problem-solving skills.

People with GAD tend to have the same knowledge of problem-solving skills but are more likely to have a negative problem orientation which consists of negative beliefs about problems and their problem solving ability, and this interferes with a person's use of problem-solving skills. This leads them to not engage in active problem-solving, and instead engage in avoidance or safety behaviors.

A negative problem orientation has three primary attitudes: The tendency to view problems as threatening; doubts about one's ability to solve problems; and pessimism regarding the outcome of potential solutions.

Exercise 9.2: Emotion monitoring for problem detection (Problem Tracking Log)

Exercise 9.3: Recurring problems list

Exercise 9.4: Finding opportunities in problems

Applying problem-solving skills

• (1) Defining a problem: Focus on the facts; find the primary obstacle; Don't be too narrow in scope

• (2) Formulating a goal: Set concrete and specific goals; set realistic goals; differentiate between short-term and long-term goals

• (3) Generating solutions. Principles: Defer judgement; generate quantity; focus on solutions that are behaviors

• (4) Making a decision: Will this solution solve my problem? How much time and effort is involved? How will I feel if I choose this solution? What are the impacts of this solution short-term and long-term; Weighing the choices; Picking a solution and moving forward

• (5) Implementing a solution and assessing its effectiveness

Exercise 9.5: Problem-solving

Chapter 10: Coping with worries about hypothetical situations (pp. 195-211)

Exercise 10.1: Do you worry about hypothetical situations?

Two ways that people with GAD react to hypothetical worries: Avoidance; Neutralization 

• Avoidance: Blocking or suppressing thoughts and images; Distraction

• Neutralization: Reassuring oneself (e.g., it probably won't happen); worry hopping (example: "What if there was an earthquake and I was seriously injured? What if my children are at school and I can't reach them and they are injured or scared? What if our house is severely damaged? What if insurance doesn't cover the cost of repairs? We could lose all our savings). 

The fact that you try not to have these thoughts and the anxiety that goes with them is the main reason you keep having them. 

Exposure: Deliberately facing your fears rather than avoiding them is known as exposure. Repeatedly engaging in exposure will decrease the frequency and intensity of your danger-related thoughts. What can be learned from exposure: Anxiety has a ceiling and it decreases on its own; you can cope

Written exposure

Two major rules: Repetition (3-5 times a week for 2-3 weeks); prolonged (30 minutes per session); schedule a time; stick to one worry; include emotional reactions; write in first person and in present tense; include information from all of your senses (sight, sound, smell, taste, touch); focus on the worst case scenario; make sure your scenario is realistic.

What exposure is not: The goal of exposure is not to reduce your fear of a negative situation should it actually occur (e.g., to not care if bad things happen).

Exercise 10.2: Practicing written exposure: Practice frequently and for sufficient duration; Set a scheduled time for exposure; Don't worry about spelling or grammar; stick to the same worry topic; include your emotional reactions in your scenario

Troubleshooting written exposure: Difficulties getting started; not experiencing anxiety; increase in worry and anxiety after exposure