Modifying Standard CT for Depression and Comorbid Gad Ocd and PTSD

If the clinician determines that the depression should be treated first, we recommend that he/she administer standard CT for depression, while remaining cognizant of the potential effects that the comorbid anxiety disorder may have on treatment. If the comorbid condition negatively impacts treatment progress, then the interventions may need to be modified.

To treat comorbid depression, it is recommended that behavioral activation be emphasized, with the goals of decreasing depressed mood and increasing hopefulness and motivation for therapy. It is important that the clinician first provide a conceptualization of the link between behavior and feelings, emphasizing the role of avoidance in maintaining depressed mood. Techniques such as goal setting and scheduling of pleasurable and mastery activity can facilitate self-activation. In the first phase of treatment, patients are asked to monitor their daily activities and mood, to increase their awareness of the connection between behaviors and feelings. Next, patients are asked to select and to schedule alternative behaviors, which can include pleasurable activities (e.g., taking a bath, engaging in hobbies) and mastery activities (e.g., washing dishes, paying bills). Patients are then encouraged to try the new behaviors and to observe the effect on their mood. In recent years, a treatment for depression that emphasizes primarily behavioral activation (with less emphasis on cognitive restructuring) has been developed and refined (Martell, Addis, & Jacobson, 2001). A self-help workbook is also available for the general public (Addis & Martell, 2004). Once the depression has decreased, and if patient and therapist mutually agree, the therapy can then shift to treatment of the anxiety disorder.

When conducting standard CT for depression, the therapist can anticipate that an individual with comorbid GAD might be prone to overestimate the likelihood of a negative outcome in an impending behavioral experiment designed to treat depression. The therapist should pay attention to "what if . . . ?" thinking when discussing behavioral experiments with a patient with GAD. It is important to use Socratic questioning to explore the patient's catastrophic beliefs about the anticipated outcome of a behavioral experiment and to challenge the patient's estimate of the likelihood that a negative outcome will occur. It is also important to generate possible coping strategies and solutions in the event that a negative outcome occurs. It may also be helpful to ask the patient to make predictions and to monitor the outcome of a behavioral experiment to determine whether his/her negative predictions do indeed come true.

In the case of PTSD, clinicians may need to slow the pace of therapy, because patients may be at risk of dissociation when discussing traumatic events. It will likely be difficult to use cognitive restructuring techniques designed to challenge the content of cognitions (e.g., "What is the evidence for [a negative event?]?"), because these patients' histories include exposure to a traumatic event; thus, they may have real-life evidence to support their cognitive distortions (e.g., a rape victim may believe that "all men are dangerous"). When engaging in cognitive restructuring, it is important for the clinician not only to acknowledge the evidence from a traumatic event but also to assist the patient in acknowledging evidence that does not support the cognitive distortions (e.g., "It is true that I am the survivor of rape, but there are men in this world who are not dangerous"). Furthermore, it may be more helpful to engage in interventions designed to modify the process of thinking, for example, by exploring the advantages and disadvantages of holding onto a particular thought and gently guiding the patient toward more helpful way of thinking.

When treating depression in patients who also have comorbid obsessions, it is also recommended that clinicians use cognitive interventions designed to alter cognitive processes rather than challenge the content of patients' thinking. Patients with obsessions, in particular, need psychoeduca-tion regarding the lack of dangerousness associated with obsessions, because their catastrophic interpretations of the obsessional thoughts or images lead to increased anxiety and distress. 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). In addition, deficits in metacognitive processing, or thinking about thinking, have been implicated in both depression and GAD; thus, interventions designed to increase meta-cognitive awareness and control may effectively treat both the anxiety and the depression. For example, monitoring of automatic thoughts and identifying common themes can be helpful in increasing awareness of thought processes. In addition, helping patients to generate a list of metacognitive statements (e.g., "Thoughts are just thoughts and I do not have to pay attention to them") may also aid in reducing distress associated with worry, obsessions, and depressive thinking.

In the next section, we discuss specific interventions to treat the anxiety disorder that may be needed as adjuncts to standard CT for depression.

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