Assessment Of Comorbidity Of Gad Ocd And Ptsd

Due to the high rate of current co-occurrence between depression and anxiety, it is always important for the clinician to inquire about anxiety disorders when interviewing patients who present for treatment of depression. However, the need to inquire is accentuated when "soft signs" are present. For example, a patient with a history of abuse would prompt a clinician to inquire about PTSD. A history of unreasonable fears, such as those related to contamination, would indicate the need to screen for OCD. A patient who repeatedly discusses worries regarding the future may prompt the clinician to inquire about GAD.

Due to time pressures of managed care, an assessment of comorbidity that includes both diagnostic precision and the information needed to develop a treatment plan likely requires more than one or two assessment sessions. It is important first to establish that the individual meets, for example, the DSM-IV diagnostic criteria (American Psychiatric Association, 2000). The incorporation of a structured diagnostic interview, such as the Structured Clinical Interview for DSM-IV Axis I disorders (SCID; First, Gibbon, Spitzer, & Williams, 1996) or the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; Di Nardo, Brown, & Barlow, 1994), can assist in a thorough assessment and is generally more reliable than a clinical interview in diagnosing comorbidity (Zimmerman & Mattia, 1999). One possible reason for the poor comorbidity detection rate in unstructured interviews is that clinicians often focus on the chief complaint and neglect to broaden the assessment to include other areas of functioning.

The temporal relationship between the depression and the comorbid anxiety disorder ought to be assessed to establish primary and secondary diagnoses. A longitudinal history is critical in understanding the development of the comorbid conditions and assists in developing a case formulation. It is important to assess the age of onset for each condition and the context in which each set of symptoms developed. In addition, it is important to inquire about early childhood experiences and traumas, as well as relationship and work/school history. This information helps the clinician understand factors that may have fostered the belief system that underlies the patient's psychological vulnerability, and leads to the development of a CT treatment plan.

The clinician should also gather a thorough list of the patient's reported anxiety and depressive symptoms. From this list, the clinician can inquire about how the anxiety and depressive symptoms relate to each other, which aids in understanding the patient's situation, to guide choices for the selection of psychotherapy and medication if needed (Belzer & Schneier, 2004). It has been recommended that clinicians inquire about the relationship between the symptoms (Belzer & Schneier, 2004). Did one set of symptoms clearly emerge, or was onset of both conditions simultaneous? For example, one patient reported that his OCD contamination fears emerged first, then the depression followed as a result of the impairments caused by the OCD. Do symptoms wax and wane concurrently? Individuals with comorbid depression and PTSD may report that as the severity of intrusive thoughts increases, they notice that their mood lowers and they begin to feel more hopeless about their future. Does one symptom seem to lead to the other or does each seem to exist on its own? What role do stressors play in the fluctuation or recurrence of each set of symptoms over time? For example, an individual with comorbid GAD and depression may report a tendency to ruminate about past mistakes but when engaged in a future-oriented task, worry about potential negative outcomes and his/her ability to cope. In addition, we recommend that clinicians assess for maladaptive coping strategies, including the abuse of substances.

The clinician can enhance rapport with the patient while also gathering information that assists in the formulation and treatment plan by inquiring about the patient's own perception of the etiological relationship between his/her anxiety and depression (Belzer & Schneier, 2004). Such information can assist clinician and patient in establishing which disorder is the most distressing and ought to be the focus, at least initially, oftreatment.

In addition to interview methods, numerous self-report measures are available for assessing general psychopathology and specifically GAD, OCD, and PTSD. The findings from self-report can be integrated with the results from a structured or clinical interview, as well as with other depression-

related self-report inventories. There are two major advantages to incorporating quantitative measures of the severity of symptoms. First, pretreatment measures of the severity of symptoms can be used to gauge which disorder is more severe and ought to be the initial focus of treatment. Even though one disorder may be temporally primary, a secondary disorder that is of greater severity and more distressing needs to be managed before treating the primary condition. Alternatively, the clinician may choose to target the less severe problem that may lead to the quickest success, thus increasing patient motivation for addressing more severe difficulties later. Another advantage is that self-report inventories can be administered repeatedly over the course of therapy to track changes in both conditions and to monitor treatment progress. A detailed list of the available inventories is beyond the scope of the chapter (see Antony & Barlow, 2002; Nezu, Ronan, Meadows, & McClure, 2000).

To aid in treatment planning, it may also be necessary to gather information regarding the cognitive and behavioral features of the disorders. Campbell and Brown (2002) suggest that individuals with GAD may engage in habitual "worry behaviors," such as making extensive and detailed lists, seeking reassurance from loved ones to ascertain their safety, and forgetting to do important tasks. These behaviors may relieve the anxiety in the short term by creating a greater sense of control over feared outcomes, but they serve to maintain the anxious belief that something terrible will happen. Such behaviors prevent the patient from learning that these fears are unfounded. Also, avoidance can increase depression because of a reduction in reinforcement secondary to the avoidance (e.g., an individual who avoids activities that involve other people fails to receive positive reinforcement from others, which leads to the emergence of depression). Thus, it is important to ask patients about the behaviors that they do to reduce their anxiety. Individuals with GAD also tend to have time-management and problemsolving deficits that result from, as well as exacerbate, their worry and tension. They may worry so much about a problem that they fail to engage in the tasks needed to fulfill other obligations. The clinician may need to ask whether worry ever interferes with the ability to complete tasks. To inquire about problem-solving deficits, the clinician can ask whether worrying leads to effective solutions to problems, or whether the patient has other ways of solving problems when they arise. "Meta-worry" (Wells & Carter, 1999) is a cognitive process that involves appraisals of the functions and consequences of worry. An individual with GAD may hold positive and negative beliefs about worrying. Understanding the beliefs that an individual holds about worry is important for treatment planning. For example, it would be diffi cult to attempt to reduce worry if a patients holds illogical positive beliefs about the benefits of worrying.

For OCD, it may be necessary to collect detailed information regarding the specific cues that cause the patient's distress, patterns of avoidance, rituals, and feared consequences (Foa & Franklin, 2001). Information is also needed regarding the environmental cues (e.g., bathroom floors, toilets, going to bed) and the internal threat cues (e.g., images, impulses, or abstract thoughts) that trigger compulsions. In addition, it is important to gather details pertaining to the feared consequence(s). For example, a patient may perform washing rituals due to a fear that someone else will become ill. It is also important to investigate the strength of the individual's belief in the obsessions and compulsions, and the degree to which he/she recognizes that these thoughts and behavior are irrational. It is also essential to assess the degree to which a patient feels responsible for his/her thoughts (Salkovskis, 1985). Finally, the clinician ought to gather information regarding the patient's patterns of avoidance, both subtle and obvious.

PTSD has a number of features that warrant assessment consideration. Avoidance, shame, and embarrassment are common features in PTSD, and many patients are reluctant to discuss the details of the trauma they endured. Thus, it is important that the clinician be especially mindful of the potential to "retraumatize" during a detailed assessment of the patient's experience (Litz, Miller, Ruef, & McTeague, 2002). It is especially recommended that clinicians create an interpersonal context of safety and trust during the assessment of PTSD. Therapists should pay attention to emotional reactions during the discussion of trauma and gather only the information that is needed to establish a diagnosis. Because incompletion of treatment is common (Ehlers et al., 2005), building trust and rapport with patients with PTSD increases the likelihood that they will return to treatment.

Because of the complexity of comorbidity, self-monitoring homework may be especially useful in the assessment and treatment planning stages. At the end of the initial assessment session, the clinician can assign homework in which the patient is asked to rate depression and anxiety levels three times per day. The patient's situational details, and any feelings and thoughts that occur, can also be monitored at each recording. By reviewing the patterns of recordings, the clinician can determine the relative severity of each condition, and this information can assist him/her in both understanding the nature of the comorbidity and determining how best to treat it. In addition, the relationship between symptoms can be investigated in a detailed manner, leading to a better understanding of the situation for both the patient and therapist.

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