The case conceptualization of comorbidity is crucial in treatment. The approach described in this section is adapted from Persons and Davidson (2001). The case formulation needs to be modified to account for comorbidity between depression and GAD, OCD, or PTSD.
For the patient with comorbidity, the problem list likely includes difficulties related to both depression and the anxiety disorder. Some of these problems may result from the depression, the anxiety, or both disorders. The patient's mood, cognitive, behavioral, situational, and interpersonal difficulties need to be described in concrete terms. For GAD, OCD, and PTSD, avoidance may be a particularly prominent problem. Patients with GAD may use worry as a way to avoid more salient emotional topics (Borkovec, 1994), whereas patients with OCD may avoid stimuli that trigger their obsessions and compulsions, and patients with PTSD may avoid situations that trigger their intrusive thoughts related to the traumatic event. Unique problems for patients with GAD might include uncontrollable worry, muscle tension, interpersonal problems as a result of reassurance-seeking behavior, time-management problems or poor problem-solving skills.
In the case of comorbidity, a working hypothesis needs to adapt cognitive theory to describe the relationship between problems on the patient's individual problem list. A working hypothesis based on a cognitive theory describes the relationship between the precipitants and the schemas (core beliefs about self, world, and others) and processes that, when activated, led to the disorders. The working hypothesis statement is an attempt to understand how the comorbid conditions developed and relate to one another, and it is continually refined and reformulated throughout treatment as additional information is gathered.
The case formulation also includes a postulation of how early childhood-adulthood experiences may have contributed to a psychological vulnerability that, when activated by life stressors, led to the emergence of each condition. Early experiences of uncontrollability may represent the psychological vulnerability for anxiety disorders, particularly for GAD (Barlow, 1991). Borkovec (1994) has suggested that childhood histories of psychosocial trauma (e.g., death of a parent, physical/sexual abuse) and insecure attachment to primary caregivers may be childhood origins that lead to the development of a psychological vulnerability for GAD. For PTSD, prior negative experiences and traumas may exert influence and give additional negative meaning to the traumatic event (Ehlers & Clark, 2000). Clinicians should consider life experiences when developing a working hypothesis about a case of comorbidity.
Barlow (1991) suggested that the onset of depression in the context of a primary anxiety disorder is dependent on the extent of one's psychological vulnerability, the severity of the current stressor, and the coping mechanisms available. Comorbidity arises when psychological vulnerability is high, the current stressor is of greater severity, and there are few coping mechanisms. It has been postulated that "pure" anxiety is the result of perceptions of uncertainty and helplessness, whereas comorbid anxiety and depression arise when helplessness is prolonged and the individual eventually gives up, loses hope, and becomes depressed (Mineka & Nugent, 1995). To illustrate this concept, Barlow (1991, p. 14) suggested that, in the face of life stress, the anxious individual thinks, "That terrible event is not my fault but it may happen again, and I may not be able to cope with it but I've got to give it a try," whereas the anxious-depressed individual might think, "That terrible event may happen again and I won't be able to cope with it, and it's probably my fault anyway so there's really nothing I can do."
The case conceptualization should also include core beliefs that are hypothesized to lead to the manifestation of the disorders. It has been theorized that pathological worry in GAD is associated with perceptions that the world is a threatening place, and that one will not be able to cope with or control future negative events (Brown, O'Leary, & Barlow, 2001). A number of obsessive-compulsive beliefs have also been identified; in particular, individuals with OCD tend to have an inflated sense of responsibility for their intrusive thoughts (Salkovskis, 1985). In addition, beliefs about the over-importance of thoughts, such as the belief that thoughts are morally equivalent to actions, otherwise known as thought-action fusion, may be present (Rachman, 1993). Metacognitive beliefs (i.e., beliefs about the importance of controlling one's thoughts) have also been proposed to be a core dysfunction in OCD (Clark & Purdon, 1993). Beliefs in relation to perfectionism and excessive concern over mistakes have also been implicated in OCD (Frost & Steketee, 1997). Ehlers and Clark (2000) proposed that individuals with PTSD hold dysfunctional external beliefs ("The world is a dangerous place") and internal beliefs (the view that one's capability, acceptability, or survivability has been threatened).
In addition to specific cognitive content, most anxiety disorders also involve a process of attentional bias, which is thought to maintain the disorder (Clark, 1999); thus, this may also need to be considered in the development of a case formulation of comorbidity. "Low tolerance of uncertainty," defined as the way in which an individual perceives and responds to infor mation in uncertain or ambiguous situations, is also a central feature in GAD (Dugas, Gagnon, Ladouceur, & Freeston, 1998) and is thought to exacerbate the "what if. . . ?" thought processes that arise in GAD. Individuals with OCD tend to conclude that situations are dangerous based on the absence of evidence for safety, but fail to conclude from information about the absence of danger that a situation is safe. Rituals are performed in attempt to reduce the likelihood of harm but never provide evidence of safety, and therefore, need to be repeated (Foa & Franklin, 2001). In addition, patients with PTSD may overgeneralize from the original event, consequently, perceiving a range of normal events as more dangerous than they really are (Ehlers & Clark, 2000).
It is especially helpful to explain in a manner that the patient understands that the two conditions exist and how they may have developed. The case conceptualization should be discussed in a collaborative way to foster trust and rapport, by eliciting feedback from the patient regarding his/her own perceptions of the problems. From the problem list generated by the clinician and patient, goals for treatment and a treatment plan can be derived.
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