Treatment Of Worry In Trauma-Exposed Individuals: Reducing Cognitive Avoidance To Facilitate Trauma-Focused Emotional Processing
By Lizabeth Roemer, Ph.D.
NCP Clinical Quarterly 7(3): Summer 1997
"If I don’t get to sleep tonight, my presentation will go badly tomorrow. Then my boss will be disappointed and I won’t get that promotion. Without the money from the raise, how will I pay for Josh’s braces? Without braces, he’ll be teased in school. Then he won’t to do well in his classes. Then he won’t get into a good college. Then what will become of him? I’ve got to get to sleep! …"
The above excerpt is an example of worry: A cognitive activity that involves anticipating multiple potential future negative outcomes. Thoughts of one negative outcome lead to thoughts of another negative outcome in a continuous chain of anxious apprehension. Although some researchers have proposed that worry may be adaptive in certain forms (1), a body of evidence attests to its detrimental nature (2). Worry is associated with muscle tension, insomnia, impaired concentration, anxiety, and dysphoria. Chronic and pervasive worry can reach clinical levels: It is the central defining feature of generalized anxiety disorder (GAD) and is a common factor across anxiety disorders (3).
Trauma And Worry
Chronic, excessive worry is a common element of post-trauma adaptation. This clinical phenomenon (in the form of GAD) has been documented in post-trauma populations, often in conjunction with post-traumatic stress disorder. In the National Comorbidity Study, 16% of individuals diagnosed with PTSD also met criteria for GAD, significantly higher than the prevalence of GAD among nonPTSD individuals (4). The National Vietnam Veterans Readjustment Survey also documented a significant comorbidity between GAD and PTSD among Vietnam theater veterans (5). A study of the psychological sequelae of the Mount St. Helen’s disaster found that GAD was one of the most prevalent disorders among survivors (6). Even in an analogue population, individuals who reported traumatic exposure reported significantly higher levels of GAD symptomatology than did those who denied any previous exposure (7).
The relationship between trauma and GAD has also been explored in the other direction. Studies have investigated the prevalence of exposure to potentially traumatizing events among individuals diagnosed with GAD. Higher rates of traumatic exposure are reported by both analogue and clinical GAD individuals than their nonanxious counterparts (8). This study, coupled with those above, indicates that for a group of individuals, traumatic exposure and worry are likely to co-occur and perhaps be inter-related. This association in no way suggests a one-to-one relationship between these phenomena. Some individuals worry excessively who have never been exposed to a trauma, and some trauma-exposed individuals do not have any difficulties with worry. Still, the overlap that has been observed bears further consideration in order to better treat those individuals for whom a history of trauma and the habit of worry co-occur.
A Theoretical Framework For Understanding The Relationship Between Trauma And Worry
Before devising an approach to treating worry in trauma victims, we need a theoretical framework in which to understand the function of worry in these individuals. Theories of worry posit that avoidance plays a primary functional role in the etiology and maintenance of the phenomenon (2, 9). Laboratory studies have demonstrated that worrying about a feared event prior to imagining the event reduces the autonomic arousal associated with the imagery (10). Thus, worry decreases uncomfortable physiological responses associated with exposure to threatening images. Further, in an investigation of perceived functions of worry, the only perceived function that differentiated chronic worriers from nonworriers was "I worry to distract myself from more emotional material" (11). Thus, engaging in worry distracts from emotional distress and reduces anxious arousal, thereby negatively reinforcing the habit. However, the habit itself becomes aversive and individuals have difficulty controlling it (12).
Similarly, avoidance is considered a key factor in conceptualizations of PTSD. Individuals exposed to an overwhelming event naturally attempt to avoid thoughts, feelings, and reminders of the event, and responses that reduce arousal and intrusions for these individuals are negatively reinforced. In addition to the avoidance symptoms of the disorder itself (avoiding thoughts, feelings and situations, detachment, emotional numbing), comorbid conditions such as substance abuse are thought to function as avoidance strategies. It is likely that worry serves a similar function in traumatized individuals. The cognitive focus on future worries is likely to distract from recollections of the traumatic experience at least in the moment, providing negative reinforcement. Similarly, reductions in somatic arousal would be reinforcing for these individuals who are likely to be hyperaroused.
It may seem then that worry serves a useful function among individuals who have been through a trauma in that it reduces some of the most salient PTSD symptomatology. However, as discussed above, worry has its own negative correlates and becomes an unwanted activity in its own right. Further, this reduced arousal and distraction only serve to maintain threatening meanings in the long term, interfering with successful resolution of the traumatic memory. A common element in dynamic, experiential and behavioral theories of emotional processing is the notion that avoidance of an emotional memory interferes with its resolution. Thus, worry, which promotes avoidance of emotional material, is likely to interfere with the efficacy of trauma-focused treatments.
Assessment Of Worry And Trauma
Given worry’s avoidant function, it is important to assess degree of worry among trauma-exposed individuals. Unassessed worry may continue to serve as a distraction for individuals and interfere with emotion-focused treatment. The Penn State Worry Questionnaire is a brief, well-validated measure of worry which can provide the clinician with an indication of the degree of habitual worry a client is engaging in (13).
In addition to assessing worry among trauma victims, it is important to assess trauma among individuals with GAD. Little is known about the range of factors that lead to chronic worry, however it seems that traumatic exposure may be one etiological pathway (8). If worry is being perpetuated because the avoidance of traumatic material is negatively reinforcing, it is important to be aware of that relationship and incorporate a trauma-focus into traditional GAD treatments.
Treatment of Generalized Anxiety Disorder and Worry in Trauma-exposed individuals
Focus of treatment
When a client presents with a traumatic history and clinical levels of worry and generalized anxiety disorder, the clinician is faced with a decision to make regarding focus of treatment. Given that worry is likely to interfere with successful processing of the traumatic experience, some attention needs to be paid to directly treating this symptom. However, it is important to acknowledge the relevance of the traumatic history and not to collude in avoidance of this threatening material. An initial focus on psychoeducation regarding the function of worry following a traumatic event will effectively accomplish this goal.
An appropriate clinical decision might be to focus first on treating the individual’s chronic worry, in order to facilitate subsequent trauma-focused work. However, clinicians should keep in mind that such treatment is unlikely to be sufficient, and should be followed by or conducted concurrently with trauma-focused treatment. To assist in the worry-focused element of treatment, I highlight below the essential components of effective treatment for generalized anxiety disorder developed by Borkovec. This cognitive-behavioral approach aims to replace a pattern of rigid, habitual, primarily cognitive, worrisome responding with more flexible, adaptive patterns of cognitive, emotional and behavioral responses. This description is necessarily brief; more detailed descriptions are available elsewhere (14).
Psychoeducation
In addition to providing clients with an understanding of the interplay between traumatic symptomatology and worry, it will be useful to outline a general theory of anxiety. Clients should be informed of the adaptive nature of anxious reactions, the multiple levels of anxious responding (subjective, behavioral, physiological, cognitive), the habitual nature of these responses, and the negatively reinforcing aspect of avoidance. Particular attention should be paid to the rigid nature of worrisome thinking and responding, as this will set the stage for the focus on increased flexibility that is central to this treatment.
Monitoring
An essential component of treatment of GAD is the initiation of careful monitoring of anxious responding. Clients should engage in this monitoring between sessions (noting their anxiety levels at several points during the day, whenever they change tasks, whenever they encounter certain already noted threatening cues) and therapists should engage in careful monitoring of anxious responding in session, noting facial and postural indices of anxiety and sharing these observations with the client.
Monitoring lays an important foundation for all subsequent treatment by accomplishing two essential goals. First, increased awareness of cues for anxious responding aids in understanding the function of this responding. If in fact worry serves to avoid other distressing material, careful monitoring will reveal the context in which worry occurs, providing information about the material being avoided. For instance, an individual who notes worrying about minor matters whenever she is in the presence of men may realize that men are serving as a traumatic reminder of her rape, and that this event requires further focus in treatment.
Second, increased awareness of cues for worry assists in early implementation of coping responses. The earlier in the chain of worry an individual is able to implement a coping response, the more effective that coping will be. An individual who is able to relax prior to entering a known anxiety-provoking situation is going to fare considerably better than one who reaches a state of near-panic before attempting to cope with their anxiety. Successful coping is the most powerful reinforcer of adaptive responding and increases the chances of future coping.
Applied Relaxation
Relaxation is thought to be particularly beneficial in the treatment of GAD for a number of reasons. Relaxation has demonstrated efficacy in reducing several of the negative correlates of worry i.e., muscle tension, impaired concentration, insomnia, anxiety. Relaxation is thought to give individuals a sense of mastery that allows them to enter situations otherwise avoided, and stay in situations despite cued anxiety. Also, in a relaxed state, thoughts and reactions are slower, increasing opportunities for deliberate, adaptive responding rather than automatic, rigid responding (see cognitive flexibility section below). Similarly, relaxation is thought to deepen emotional processing, allowing more complete experience of a range of emotions, whereas worry inhibits this process. In general, relaxation promotes behaviors that serve the function of approaching threatening stimuli (both internal and external), in contrast to the avoidance behaviors associated with worry.
It is advisable to introduce several methods of relaxation so that the client can have a number of options available. Early in treatment, training in diaphragmatic breathing can be extremely helpful. A client can use this technique immediately and often notice changes as early as by the second session, increasing expectancies and treatment motivation. Formal training in progressive muscle relaxation (15) can also be initiated, along with applied relaxation in which an individual is taught to initiate a relaxed response at the first sign of anxiety. Pairing relaxation with a pleasant image can facilitate its flexible application. Again, the success of any relaxation technique rests on early cue detection and implementation.
Exposure-Based Techniques
Consistent with the notion that worry is initiated in response to threatening stimuli, and becomes an anxiety provoking stimulus in and of itself, it is recommended that treatment incorporate some form of repeated exposure to threatening cues. Borkovec uses self-control desensitization in which anxious cues are presented imaginally and coping responses are initiated at the moment of increased anxiety and continued until anxiety subsides. This process is repeated until either no anxiety is elicited by the cues, or the coping immediately reduces anxiety. Barlow and colleagues (16) advocate a procedure more similar to flooding (worry exposure) in which a worst case scenario is presented for an extended period of time, and is then followed by coping responses.
Regardless of the technique employed, the central principle is repeated presentation of anxiety-provoking cues (stimulus, response and meaning) until there is a sufficient decrease in anxious responding. This corrective information is then incorporated into the memory network, lessening the threatening meaning of the cues (17). Exposure can be implemented imaginally as described above, or through in vivo behavioral experiments. For instance, a client might be encouraged to enter an anxiety-provoking situation, relax rather than worry, and discover that in fact nothing horrible happens (often worriers believe that their worry serves to protect them from negative outcomes). The exposure-based component of this treatment will facilitate transition into trauma-focused treatment which follows the same general principles.
Cognitive Flexibility
Worry is a cognitive process which is characterized by rigid, automatic thinking typical of anxious individuals (18). A generally anxious individual is likely to overinterpret threat, set extremely high standards for him/herself, engage in self-blame, and overestimate the likelihood of negative outcomes. Comprehensive treatment must attend to the thought process of a chronic worrier, with the goal of encouraging flexible perspectives. This can be accomplished formally through traditional cognitive techniques (19). Alternatively, a general spirit of therapy that encourages consideration of multiple perspectives and promotes a spirit of continual questioning of previously assumed truths will meet the same goal.
Because chronic worriers often have the experience of being "lost in their heads" with endless thoughts and predictions running through their head (2), it is important that a cognitive focus not perpetuate this style. Therefore, a focus on cognitive flexibility and generation of multiple alternative perspectives is considered preferable to standardized training in "rational", error-free thinking. Further, integration of cognitive approaches with a focus on somatic experience (e.g., relaxation) and a range of emotional experience (e.g., exposure-based techniques) is advised. As mentioned above, relaxation training will facilitate the production of alternate perspectives by slowing the stream of automatic thoughts so they can be questioned and explored more effectively.
Special Considerations For Trauma-Focused Treatment
The primary goal of the trauma-focused component of treatment is facilitating emotional processing of trauma-related thoughts, feelings, memories, and images. For chronic worriers, particular attention should be paid to subtle forms of avoidance, such as focus on superficial, minor, worrisome concerns rather than underlying, threatening emotional material. Worry, and anxiety in general, may be more acceptable, less aversive, emotional experiences for these individuals, necessitating a therapeutic focus away from these emotions to more relevant, primary emotions of fear, guilt, shame, anger, and grief that are likely to accompany traumatic memories. Even relaxation, introduced during the worry-focused phase of treatment, might be used as an avoidant response during the trauma-focused intervention. It will be important to address this directly and clearly distinguish between using relaxation to deepen and expand emotional experience and using it to avoid threatening stimuli.
Conclusion
For some individuals, exposure to a traumatic experience will result in chronic anxious apprehension or worry, as well as post-traumatic stress disorder. Treating these individuals should incorporate worry-focused treatment and should proceed with an awareness of how worry may serve an avoidant function and interfere with successful emotional processing of the traumatic event. The primary challenge of this combined treatment is distinguishing between primary emotional reactions and secondary, avoidant responses in order to determine appropriate targets for exposure-based treatment.
References
1. Tallis, F. Davey, G.L., & Capuzzo, N (1994). The phenomenology of non-pathological worry: A preliminary investigation. In G.L. Davey & F Tallis (Eds.), Worrying: Perspectives on theory, assessment, and treatment (pp. 61-89). New York: John Wiley & Sons.
2. Borkovec, T.D. (1994). The nature, functions, and origins of worry. In G.L. Davey & F. Tallis (Eds.), Worrying: Perspectives on theory, assessment, and treatment (pp. 5-34). Sussex, England: Wiley & Sons.
3. Barlow, D.H. (1988). Anxiety and its disorders. New York: Guilford Press.
4. Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060.
5. Kulka, R., Schlenger, W., Fairbank, J., Hough, R., Jordan, B., Marmar, C., & Weiss, D. (1990). Trauma and the Vietnam war generation. New York: Brunner-Mazel.
6. Shore, J.H., Tatum, E.L., Vollmer, W.M. (1986). Psychiatric reactions to disaster: The Mount St. Helens experience. American Journal of Psychiatry, 143, 590-595.
7. Roemer, L., Molina, S., Litz, B. T., & Borkovec, T. D. (1997). A preliminary investigation of the role of potentially traumatizing events in the development of generalized anxiety disorder. Depression and Anxiety, 4, 134-138.
8. Roemer, L., Litz, B.T., Pepper, C.M., & Borkovec, T.D. (1995, November). The relationship between worry and PTSD following exposure to potentially traumatizing events. Paper presented at the 29th Annual Convention of the Association for Advancement of Behavior Therapy, Washington, D.C.
9. Mathews, A. (1990). Why worry? The cognitive function of anxiety. Behavior Research and Therapy, 28, 455-468.
10. Borkovec, T.D., & Hu, S. (1990). The effect of worry on cardiovascular response to phobic imagery. Behaviour Research and Therapy, 28, 69-73.
11. Borkovec, T.D., & Roemer, L. (1995). Perceived functions of worry among generalized anxiety disorder subjects: Distraction from more emotional topics? Journal of Behavior Therapy and Experimental Psychiatry, 26, 25-30.
12. Roemer, L., & Borkovec, T.D. (1993). Worry: Unwanted cognitive experience that controls unwanted somatic experience. In D.M. Wegner, & J.W. Pennebaker (Eds.), Handbook of mental montrol (pp. 220-238). Englewood Cliffs, NJ: Prentice-Hall.
13. Meyer, T.J., Miller, M.L., Metzger, R.L., & Borkovec, T.D. (1990). Development and validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 28, 487-496.
14. Borkovec, T. D. & Roemer, L. (1994). Cognitive behavioral treatment of generalized anxiety disorder. In R. T. Ammerman & M. Hersen (Eds.), Handbook of prescriptive treatments for adults (pp. 261-281). New York: Plenum.
15. Bernstein, D.A., & Borkovec, T.D. (1973). Progressive relaxation training. Champaign, IL: Research Press.
16. Brown, T.A., O’Leary, T.A., & Barlow, D.H. (1993). Generalized anxiety disorder. In D.H. Barlow (Ed.), Clinical handbook of psychological disorders - 2nd ed. (pp. 137-188). New York: Guilford.
17. Foa, E.B., & Kozak, M.J. (1986). Emotional processing of fear: exposure to corrective information. Psychological Bulletin, 99, 20-35.
18. Beck, A.T., & Emery, G. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books.
19. Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press.
Lizabeth Roemer is an Assistant Professor in the Department of Psychology at the University of Massachusetts at Boston. Her research focuses on elucidating the mechanisms of emotional avoidance in order to improve interventions aimed at reducing post-traumatic symptomatology.
|
