1- Generalized Anxiety Disorder (Checklist)

Case 1: (pp. 1-15)

Correct Answer: B) They are not associated with any physical dependence

Explanation:
Research shows that benzodiazepines, while effective in the short term, may impair driving, increase the risk of hip fractures in the elderly (Ray et al., 1992; Wang et al., 2001), and lead to psychological and physical dependence (Rickels et al., 1990).

Research Update Note:
Benzodiazepines are still used, but current guidelines (APA, NICE, 2023) recommend them only for short-term crisis use, with SSRIs/SNRIs as first-line long-term options.

Which of the following is a major limitation of benzodiazepine use in the treatment of GAD, according to research?

A) They are highly effective for long-term symptom management
B) They are not associated with any physical dependence
C) They may impair driving and increase fall risk in the elderly
D) They eliminate the need for psychological treatment

Correct Answer: B) Antidepressant medications (e.g., venlafaxine, paroxetine)

Explanation:
Antidepressants, particularly SSRIs and SNRIs (venlafaxine, paroxetine), have been shown to provide better long-term effectiveness in GAD compared to benzodiazepines (Brawman-Mintzer, 2001; Craske & Barlow, 2006).

Research Update Note:
Other SSRIs/SNRIs (escitalopram, duloxetine) are now widely supported by meta-analyses (Cipriani et al., 2018; Baldwin et al., 2021) as first-line pharmacological treatments.

Which medications have been found to show better effectiveness than benzodiazepines in the treatment of GAD?

A) Antipsychotic medications (e.g., risperidone)
B) Antidepressant medications (e.g., venlafaxine, paroxetine)
C) Mood stabilizers (e.g., lithium)
D) Beta-blockers (e.g., propranolol)

Correct Answer: B) They had equal or lower effectiveness compared to placebo psychotherapies

Explanation:
Initial studies suggested that psychological treatments (e.g., relaxation training, general reassurance) were not more effective than placebo psychotherapies because they did not directly target worry, the core feature of GAD (Roemer & Orsillo, 2014).

Research Update Note:
Modern CBT tailored to worry is now robustly superior to placebo and considered equally effective to medications in both the short and long term (Cuijpers et al., 2016; Hofmann et al., 2022).

Early studies of psychological treatments for GAD showed which of the following findings?

A) They were significantly more effective than placebo psychotherapies
B) They had equal or lower effectiveness compared to placebo psychotherapies
C) They showed no effect on GAD symptoms
D) They were completely superior to pharmacological treatments

Correct Answer: C) 58%

Explanation:
In Borkovec and Costello (1993), about 58% of patients achieved high endstate functioning (minimal or no symptoms) at 1-year follow-up. This showed that CBT targeting worry was more effective than placebo, but still left room for improvement.

Research Update Note:
Recent acceptance-based CBT and mindfulness-enhanced therapies report similar or slightly better long-term recovery rates (~60–70%), but still highlight the chronic and treatment-resistant nature of GAD in many individuals.

What percentage of patients in Borkovec and Costello’s (1993) study achieved “high endstate functioning” at 1-year follow-up after CBT for GAD?

A) 25%
B) 42%
C) 58%
D) 80%

Correct Answer: B) Acceptance rather than avoidance of distressing thoughts and feelings

Explanation:
Acceptance-based approaches (e.g., Acceptance and Commitment Therapy, mindfulness-based strategies) have been incorporated into CBT to help patients tolerate worry-related thoughts rather than avoid them, showing promising results (Roemer & Orsillo, 2014; Hayes-Skelton et al., 2013).

Research Update Note:
Recent studies (2020–2024) show mindfulness-based CBT and integrated ACT-CBT protocols may provide equal or greater benefit than traditional CBT, especially for chronic GAD cases resistant to earlier treatments.

Which newer therapy elements have been incorporated to enhance the effectiveness of CBT for GAD?

A) Psychoanalysis focusing on unconscious conflict
B) Acceptance rather than avoidance of distressing thoughts and feelings
C) Pure relaxation and reassurance techniques
D) Hypnosis-based treatments

Correct Answer: B) Excessive and uncontrollable worry about multiple events or activities

Explanation:
DSM-5 identifies excessive and uncontrollable worry about a number of events and activities as the central diagnostic feature of GAD. Earlier DSM editions defined GAD more vaguely, but refinements have clarified its unique profile.

Research Update Note:
Recent DSM-5-TR clarifications (APA, 2022) emphasize chronic, persistent worry across domains (health, finances, work, family), distinguishing GAD from other anxiety disorders.

According to DSM-5, the key diagnostic feature of GAD is:

A) Panic attacks occurring unexpectedly
B) Excessive and uncontrollable worry about multiple events or activities
C) Recurrent intrusive thoughts and compulsions
D) Specific fears related to identifiable objects or situations

Correct Answer: B) Gradually, frequently dating back to childhood

Explanation:
Unlike panic disorder or OCD, GAD has a gradual onset, often with patients recalling being anxious and tense from childhood (Newman et al., 2011).

Research Update Note:
Longitudinal studies confirm early-life anxiety traits as predictors of later GAD (Beesdo-Baum et al., 2012). Some researchers conceptualize GAD as a mix of trait anxiety and disorder-level impairment.

Research suggests that GAD often begins:

A) Suddenly in adulthood, often triggered by a traumatic event
B) Gradually, frequently dating back to childhood
C) Only in late life due to physical health concerns
D) After the onset of another major psychiatric disorder

Correct Answer: C) Lower attrition rates

Explanation:
Psychological treatments are associated with lower dropout rates compared to medications, especially in long-term treatment (Borkovec et al., 2002; Mitte, 2005a).

Research Update Note:
Recent meta-analyses (Hofmann & Smits, 2017) support lower attrition for CBT, particularly when treatment is individualized and skills-based.

Compared to medications, psychological treatments for GAD tend to show:

A) Higher attrition rates
B) Equal attrition rates
C) Lower attrition rates
D) No difference in attrition rates

Correct Answer: B) Focused mainly on nonspecific techniques like relaxation training

Explanation:
Earlier treatments often focused on general relaxation or reassurance, which did not specifically address worry, the hallmark of GAD (Brown et al., 1994).

Research Update Note:
Targeted CBT protocols now prioritize intolerance of uncertainty, worry exposure, and cognitive flexibility—showing stronger outcomes (Dugas et al., 2010).

One reason early psychological interventions for GAD were not highly effective is because they:

A) Directly targeted worry through exposure and restructuring
B) Focused mainly on nonspecific techniques like relaxation training
C) Involved too much cognitive therapy without behavior components
D) Required patients to use medications concurrently

Correct Answer: C) A therapeutic response with no or minimal GAD symptoms remaining

Explanation:
High endstate functioning is a measure used in treatment research to describe a state in which individuals show no or minimal symptoms of the disorder after therapy (Borkovec & Costello, 1993).

Research Update Note:
Modern clinical trials continue to use “response” and “remission” metrics, with remission defined similarly to “high endstate functioning.” Remission rates for GAD remain lower than for depression, averaging 50–60%.

In treatment outcome studies, “high endstate functioning” refers to:

A) A state where only mild residual symptoms remain
B) A complete elimination of all anxiety disorders
C) A therapeutic response with no or minimal GAD symptoms remaining
D) Relapse occurring after initial recovery

Correct Answer: A) Better outcomes in the long term

Explanation:
Although medications may show rapid symptom relief, psychological treatments demonstrate stronger long-term maintenance of gains with less relapse (Mitte, 2005a; Newman et al., 2011).

Research Update Note:
CBT’s long-term effects are now well-documented, with relapse prevention enhanced by acceptance- and mindfulness-based approaches (Roemer & Orsillo, 2014; Hayes-Skelton et al., 2013).

Compared to medications, psychological treatments for GAD tend to show:

A) Better outcomes in the long term
B) Worse outcomes in the long term
C) No difference in long-term outcomes
D) Equal short- and long-term superiority

Correct Answer: C) Accepting and tolerating distressing thoughts and feelings

Explanation:
Newer treatments (Roemer & Orsillo, 2014) emphasize acceptance and mindfulness, helping patients face thoughts and feelings without avoidance, which improves treatment outcomes.

Research Update Note:
Acceptance-based CBT and ACT (Acceptance and Commitment Therapy) are supported by trials (2020–2024) as effective alternatives to standard CBT, particularly for chronic or treatment-resistant GAD.

Acceptance-based therapies for GAD focus on:

A) Eliminating all worry-related thoughts
B) Avoiding distressing emotions at all costs
C) Accepting and tolerating distressing thoughts and feelings
D) Enhancing reassurance from external sources

Correct Answer: A) Work immediately to reduce worry but may impair driving and increase fall risk

Explanation (Biological/Psychoeducation):
Benzodiazepines act quickly by enhancing GABA (gamma-aminobutyric acid) activity, producing a calming effect. However, they also impair psychomotor coordination (driving, balance) and can lead to dependence, making them unsuitable for long-term GAD management.

Research Update Note:
Current guidelines recommend short-term use only (≤4 weeks), often as a “bridge” until SSRIs/SNRIs become effective (Baldwin et al., 2021).

Adrian’s clinician considers prescribing benzodiazepines to reduce her immediate distress. From a psychoeducational perspective, Adrian should understand that benzodiazepines:

A) Work immediately to reduce worry but may impair driving and increase fall risk
B) Take several weeks to become effective but have fewer long-term risks
C) Primarily reduce depressive symptoms rather than anxiety
D) Are non-addictive and safe for long-term daily use

Correct Answer: B) Both psychological and physical dependence, making discontinuation difficult

Explanation (Biological/Psychoeducation):
Benzodiazepines can cause downregulation of GABA receptors, leading to tolerance and withdrawal symptoms upon discontinuation. Patients often develop both psychological reliance (“I can’t cope without the pill”) and physical dependence.

Research Update Note:
Current best practices recommend gradual tapering under supervision, often substituting with CBT or SSRIs to manage anxiety during withdrawal.

If Adrian continues benzodiazepine use beyond the short term, what psychoeducational risk should her therapist explain?

A) Liver toxicity and weight gain
B) Both psychological and physical dependence, making discontinuation difficult
C) Long-term improvement in cognitive function
D) Permanent cure for GAD

Correct Answer: A) Have slower onset but better long-term effectiveness in GAD

Explanation (Biological/Psychoeducation):
SSRIs (e.g., paroxetine) and SNRIs (e.g., venlafaxine) regulate serotonin and norepinephrine pathways, which stabilize mood and reduce excessive worry. They require 2–6 weeks to take effect but have stronger long-term outcomes for GAD compared to benzodiazepines.

Research Update Note:
SSRIs/SNRIs are now first-line treatments for GAD, recommended by APA and NICE guidelines.

Adrian’s clinician suggests switching to an antidepressant like venlafaxine or paroxetine. Compared to benzodiazepines, these medications:

A) Have slower onset but better long-term effectiveness in GAD
B) Work faster but have higher relapse rates
C) Eliminate worry instantly through dopamine pathways
D) Cause no side effects and require no monitoring

Correct Answer: B) Medications lower baseline anxiety, making it easier to engage in therapy

Explanation (Biological/Psychoeducation):
Medications regulate neurotransmitter activity, reducing physiological arousal, while CBT teaches skills for managing worry and intolerance of uncertainty. Together, they help Adrian engage more fully in therapy while preventing relapse after tapering off medication.

Research Update Note:
Evidence suggests combination therapy can be effective, though CBT alone often sustains longer remission once medication is stopped (Cuijpers et al., 2016).

Adrian begins CBT while taking medication. From a psychoeducational perspective, which explanation would help her understand why combining treatments may help?

A) Medications cure anxiety by removing all triggers permanently
B) Medications lower baseline anxiety, making it easier to engage in therapy
C) CBT prevents medication side effects
D) Therapy ensures faster absorption of medication in the bloodstream

Correct Answer: B) Dysregulation in amygdala-prefrontal cortex circuits leads to impaired worry control

Explanation (Biological/Psychoeducation):
Research shows that in GAD, amygdala hyperactivity (fear/anxiety response) combines with reduced prefrontal regulation (cognitive control), leading to excessive and uncontrollable worry. Medications and CBT both work to restore balance in these circuits.

Research Update Note:
Neuroimaging studies confirm that SSRIs normalize prefrontal-amygdala connectivity, while CBT strengthens prefrontal regulation through learning and exposure.

Adrian asks why her worry feels uncontrollable. From a biological standpoint, which explanation would be most accurate for psychoeducation?

A) Overactivation of dopamine circuits causes excessive planning behavior
B) Dysregulation in amygdala-prefrontal cortex circuits leads to impaired worry control
C) Low levels of acetylcholine drive repetitive thought loops
D) Serotonin levels rise too quickly, leading to overthinking

Correct Answer: B) Both medications and therapy may help, but relapse is possible without continued skills practice

Explanation (Biological/Psychoeducation):
Patients benefit from realistic expectations: medications reduce symptoms, therapy builds coping skills, and relapse can occur if stressors reappear and skills are not maintained.

Research Update Note:
Maintenance CBT and mindfulness-based therapies are increasingly used to prevent relapse and enhance long-term recovery in GAD.

Psychoeducation on Treatment Expectations

When psycho-educating Adrian about GAD treatment, it is important to emphasize that:

A) Medications alone will cure her GAD permanently
B) Both medications and therapy may help, but relapse is possible without continued skills practice
C) Benzodiazepines are more effective than therapy in long-term outcomes
D) Worry can be completely eliminated with proper treatment

Answer: C) Sedation and motor impairment leading to falls

Explanation: Benzodiazepines cause sedation and impaired motor coordination, which increases the risk of falls and hip fractures in elderly patients (Ray et al., 1992; Wang et al., 2001).
Note: Current clinical guidelines strongly recommend avoiding long-term benzodiazepine use in older adults due to this risk.

Which factor contributes to the increased risk of hip fractures in elderly patients taking benzodiazepines?

A) Reduced appetite
B) Increased bone fragility
C) Sedation and motor impairment leading to falls
D) Reduced calcium absorption

Answer: B) Because DSM-III defined it as a residual diagnosis for non-specific anxiety

Explanation: In DSM-III (1980), GAD was defined as a residual category for patients with anxiety symptoms not accounted for by other disorders. This led to underestimation of its severity. Research later showed GAD causes significant functional impairment.

Why was GAD previously considered a “less impairing” disorder compared to others?

A) Because its core symptoms were thought to be mild forms of depression
B) Because DSM-III defined it as a residual diagnosis for non-specific anxiety
C) Because it had no pharmacological treatments available at the time
D) Because it was associated only with childhood

Answer: C) Cognitive therapy with worry exposure

Explanation: Treatments developed by Borkovec and Costello (1993) and others focus on cognitive therapy plus direct exposure to worry-related images. These are more effective than nonspecific methods like reassurance or relaxation alone.

Which of the following non-medication approaches directly targets the central feature of GAD (excessive worry)?

A) Progressive muscle relaxation only
B) Supportive reassurance
C) Cognitive therapy with worry exposure
D) Sleep hygiene education

Answer: B) Shyness in childhood with increased anxiety after moving schools at 14

Explanation: Early shyness and the stressful school transition at 14 preceded persistent worry and insomnia—classic developmental risks.

Research Update Note: Temperamental behavioral inhibition and early anxious traits increase later GAD risk.

Developmental Risk Factors (Predisposing)

Which life detail best represents a predisposing risk factor for Adrian’s GAD?

A) Supervisor suggesting she take a vacation
B) Shyness in childhood with increased anxiety after moving schools at 14
C) Beginning an exercise class post-treatment
D) Clarifying her supervisor’s comment during therapy

Answer: C) Supervisor’s remark to “take some vacation time”

Explanation: She interpreted the vacation suggestion as a sign of impending termination, sharply escalating work-related worry.

Research Update Note: Ambiguous feedback at work commonly precipitates worry spirals in GAD via threat interpretation bias.

Precipitating Event (Trigger)

Which event most clearly triggered an escalation of Adrian’s current worries about work?

A) Her divorce years earlier
B) Brief marijuana experimentation in college
C) Supervisor’s remark to “take some vacation time”
D) Children playing outside for 2 hours without checking in

Answer: A) Arriving 30 minutes early daily to plan the day

Explanation: This safety behavior prevents disconfirmation (“I only avoid mistakes because I over-prepare”), thus perpetuating worry.

Research Update Note: Safety behaviors maintain anxiety by blocking new learning.

Perpetuating Factor (Work Safety Behavior)

Which behavior most maintains Adrian’s belief that she is error-prone at work?

A) Arriving 30 minutes early daily to plan the day
B) Attending an exercise class
C) Speaking with friends less often
D) Taking her migraine medication

Answer: B) Calling her children in Hungary several times per day

Explanation: Excessive checking/reassurance seeking sustains catastrophic predictions and dependence on short-term relief.
Research Update Note: Reassurance seeking is linked to higher worry persistence and functional impairment.

Perpetuating Factor (Reassurance/Checking)

Which home behavior best fits a perpetuating pattern for her child-safety worries?

A) Limiting screen time
B) Calling her children in Hungary several times per day
C) Cooking dinner earlier
D) Journaling pleasant events

Answer: C) Better sleep with reduced irritability and improved concentration

Explanation: Correcting sleep restriction (a perpetuating factor) improved daytime functioning and mood regulation.

Research Update Note: Sleep improvement reduces cognitive reactivity and daytime worry intensity.

Sleep as a Modifiable Factor

What happened when Adrian increased sleep toward 8 hours/night?

A) Worry increased; concentration worsened
B) No change in symptoms
C) Better sleep with reduced irritability and improved concentration
D) New panic attacks emerged

Answer: C) Willingness to engage in exposure and confront the supervisor

Explanation: Approach behaviors (exposure, clarification) build mastery and corrective learning.

Research Update Note: Treatment adherence and approach coping predict better GAD outcomes.

Protective Factor (Agency/Engagement)

Which is the strongest protective factor evident during treatment?

A) Avoiding social events
B) Rarely seeking clarification at work
C) Willingness to engage in exposure and confront the supervisor
D) Relying on early arrival to prevent errors

Answer: C) Residual social anxiety features (authority, assertiveness, meetings)

Explanation: The therapist linked residual concentration lapses to social evaluative contexts, consistent with her social anxiety disorder.

Research Update Note: GAD commonly co-occurs with social anxiety, and evaluative contexts can impair working memory under stress.

Comorbidity Link to Residual Symptoms

Her remaining concentration problems at work were hypothesized to be best explained by:

A) Undiagnosed ADHD
B) Persistent depressive disorder
C) Residual social anxiety features (authority, assertiveness, meetings)
D) Substance withdrawal

Answer: B) Probability overestimation with stereotype-consistent threat appraisal

Explanation: She overestimates accident risk using a biased generalization, feeding catastrophic imagery avoidance.

Research Update Note: Intolerance of uncertainty and probability overestimation are central cognitive processes in GAD.

Cultural Beliefs & Cognitive Bias

Adrian’s belief that “Hungarian drivers are the worst (except Basque Spaniards)” in the context of her kids traveling is best described as:

A) Accurate base-rate reasoning
B) Probability overestimation with stereotype-consistent threat appraisal
C) Thought-action fusion
D) Magical thinking

Answer: B) Borderline hypertension and migraine headaches

Explanation: Muscle tension, sleep loss, and sustained arousal exacerbate migraines and blood pressure; symptoms then fuel more worry.

Research Update Note: Chronic worry is linked to somatic tension and autonomic inflexibility (“autonomic restrictor” profile).

Health Domain Connection

Which physical problems likely interact bidirectionally with her worry/tension?

A) Seasonal allergies
B) Borderline hypertension and migraine headaches
C) Low iron levels
D) Knee pain

Answer: C) Impacts work accuracy, parenting (mood, calling), and dating (evaluation fears)

Explanation: The case documents broad interference: work errors/over-planning, strained parenting interactions, and anxious dating.

Research Update Note: GAD commonly causes multi-domain impairment, not just internal distress.

Life Role Impact

Which statement best captures GAD’s functional impact across Adrian’s roles?

A) Only affects parenting; work is unaffected
B) Only affects work; parenting and dating unaffected
C) Impacts work accuracy, parenting (mood, calling), and dating (evaluation fears)
D) Limited to housekeeping routines

Answer: B) (Precipitating) supervisor remark; (Perpetuating) early arrival/over-checking

Explanation: Vacation remark triggered escalation; safety behaviors maintained it.

Research Update Note: Distinguishing triggers from maintainers guides behavioral experiments and exposure targets.

Precipitating vs. Perpetuating Distinction

Which pair correctly matches precipitating vs. perpetuating for Adrian?

A) (Precipitating) early shyness; (Perpetuating) moving at 14
B) (Precipitating) supervisor remark; (Perpetuating) early arrival/over-checking
C) (Precipitating) exercise class; (Perpetuating) imaginal exposure
D) (Precipitating) improved sleep; (Perpetuating) asking supervisor for clarity

Answer: B) Stable employment and a track record of competence

Explanation: Her competence and job stability are evidence against catastrophic beliefs and provide structure and self-efficacy.

Research Update Note: Functional roles (work/parenting) can be leveraged as behavioral activation and values-based motivators.

Protective Factor (Assets/Strengths)

Which asset most likely supported recovery and resilience?

A) Frequent avoidance of social situations
B) Stable employment and a track record of competence
C) Isolation from friends
D) Refusal to discuss worries

Answer: B) Decreasing call frequency to every other day

Explanation: Reducing reassurance checking decreased anxiety and made calls more positive, weakening the worry cycle.

Research Update Note: Gradual reduction in checking is an exposure-consistent strategy that improves family interactions.

Parenting & Family Dynamics

Which change reduced tension in calls with her children?

A) Increasing call frequency
B) Decreasing call frequency to every other day
C) Switching to text messages only
D) Avoiding calls entirely

Answer: B) Gave structured time for full activation and processing, so intrusions could be deferred and diminish

Explanation: Deliberate, prolonged imaginal exposure promotes habituation and inhibitory learning, decreasing intrusions and avoidance.

Research Update Note: Exposure that targets imagery + meaning is superior to brief distraction for worry reduction.

Imaginal Exposure Mechanism (Life Application)

Why did scheduled worry exposure hours reduce daytime intrusions?

A) It suppressed thoughts permanently
B) Gave structured time for full activation and processing, so intrusions could be deferred and diminish
C) Distracted her from problems
D) Reassured her that bad events won’t happen

Answer: A) Correct mapping

Explanation: This mapping reflects the case chronology and mechanisms.

Research Update Note: 4Ps organization improves case conceptualization and treatment targeting in anxiety disorders.

4Ps Integration

Which combination best maps onto a 4Ps formulation for Adrian?
- Predisposing: childhood shyness, school move at 14
- Precipitating: supervisor’s vacation remark; kids away in Hungary
- Perpetuating: early arrival, excessive calls, sleep restriction, over-cleaning
- Protective: treatment engagement, clarification at work, improved sleep, exercise

A) Correct mapping
B) Predisposing should be supervisor remark
C) Perpetuating should be imaginal exposure
D) Protective should be excessive calling

Answer: B) Precipitating factor

Explanation: Adrian’s divorce acted as the major life stressor that triggered the escalation of GAD symptoms, making it a precipitating factor. The supervisor’s comment then reinforced existing anxiety but was not the original onset.

Research Note: Divorce is consistently documented as a precipitating risk factor for anxiety disorders, especially when it leads to themes of rejection, abandonment, and relational insecurity (e.g., Whisman, 2007).

How is Adrian’s divorce best understood in the 4Ps model of GAD?

A) Predisposing factor
B) Precipitating factor
C) Perpetuating factor
D) Protective factor

Answer: C) Because the experience reinforced catastrophic expectations of rejection and failure

Explanation: Divorce likely sensitized her to fear of relational rejection, making social evaluative situations more threatening.

Research Note: Past relational trauma can serve as a schema-level vulnerability, fueling GAD/social anxiety comorbidity.

Divorce as a Trigger of Relational Worry

Why did Adrian’s divorce likely exacerbate fears in dating later?

A) Because divorce removed protective family roles
B) Because divorce caused job loss
C) Because the experience reinforced catastrophic expectations of rejection and failure
D) Because divorce increased financial risk

Answer: B) After psychoeducation, monitoring, and building a therapeutic alliance

Explanation: Treatment followed a stepwise CBT model: first psychoeducation + worry monitoring, then gradual exposure, then restructuring.

Research Note: Structured sequencing (psychoeducation → exposure → consolidation) is evidence-based for CBT-GAD.

Timing of the Treatment Plan

When did the therapist introduce exposure-based techniques in Adrian’s treatment?

A) At intake, session 1
B) After psychoeducation, monitoring, and building a therapeutic alliance
C) Before any medication discussion
D) After full remission was achieved

Answer: B) Through recognizing patterns of reassurance seeking and rejection sensitivity

Explanation: Divorce shaped schema-driven worries (rejection, instability), which were addressed via cognitive restructuring and assertiveness exposures.

Research Note: Schema-level themes often emerge in CBT for GAD, especially where loss and rejection are salient.

Divorce in Treatment Content

How was the divorce experience addressed indirectly in Adrian’s treatment?

A) By reliving the divorce as exposure
B) Through recognizing patterns of reassurance seeking and rejection sensitivity
C) Through role-play of legal negotiations
D) By ignoring relational history

Answer: B) Self-monitoring of worry triggers and intrusions

Explanation: Monitoring helped her notice triggers (e.g., work remarks, children’s absence), preparing her for exposure-based processing.

Research Note: Worry diaries are a cornerstone of CBT for GAD, aiding metacognitive awareness.

Early Step of Treatment

Which early treatment step was most emphasized to increase awareness of Adrian’s worry cycle?

A) Group therapy participation
B) Self-monitoring of worry triggers and intrusions
C) Medication trial
D) Immediate social exposures

Answer: B) During initial sessions alongside CBT education

Explanation: Discussing SSRIs and anxiolytic effects early normalizes treatment, explains biological mechanisms, and reduces stigma.

Research Note: Combining CBT + SSRIs often enhances outcomes, especially in high-severity or comorbid GAD.

Biological & Psychoeducational Timing

When would psychoeducation on medication be most useful for Adrian?

A) After relapse only
B) During initial sessions alongside CBT education
C) Not at all—CBT only
D) After termination

Answer: B) Checking on her children too frequently

Explanation: Excessive calls were reduced systematically, testing her predictions and promoting exposure to uncertainty.

Research Note: Uncertainty tolerance training and behavioral experiments are crucial in GAD.

Targeting Perpetuating Behaviors

Which perpetuating behavior was directly targeted with behavioral experiments?

A) Attending exercise class
B) Checking on her children too frequently
C) Migraines
D) Cleaning routines

Answer: B) By reinforcing fears of loss and lack of control in caregiving

Explanation: Post-divorce, her heightened need for control over children’s safety perpetuated reassurance behaviors.

Research Note: Parental anxiety after divorce is common and predicts intergenerational worry transmission.

Divorce and Parenting Stress

How might divorce have indirectly contributed to her excessive calling/checking on children?

A) By increasing her financial worries
B) By reinforcing fears of loss and lack of control in caregiving
C) By creating new friendships
D) By reducing her work hours

Answer: B) Exposure “homework” and continued worry scheduling

Explanation: Continued structured exposure consolidated skills and maintained tolerance for uncertainty.

Research Note: Relapse prevention in GAD emphasizes maintenance of exposure and coping flexibility.

Termination & Relapse Prevention

What strategy was used to help prevent relapse after initial symptom reduction?

A) Weekly reassurance calls
B) Exposure “homework” and continued worry scheduling
C) Stopping monitoring completely
D) Ending sessions abruptly

Answer: B) Inhibitory learning and habituation

Explanation: Exposure allowed her to confront catastrophic imagery, reducing avoidance and breaking the worry cycle.

Research Note: Imaginal exposure fosters corrective learning that feared outcomes don’t occur.

Therapy Mechanism

What psychological mechanism explains why imaginal exposure to feared images helped Adrian?

A) Thought suppression
B) Inhibitory learning and habituation
C) Positive reinforcement
D) Distraction

Answer: B) Divorce

Explanation: Adrian’s divorce was the major stressful life event that triggered the initial onset of her GAD symptoms, creating the context for long-term relational and self-worth worries.

Research Note: Divorce is frequently identified as a precipitant for anxiety and depression due to loss, rejection, and destabilization of social roles.

Divorce as Disorder-Level Precipitant

Which event best fits as the precipitating factor for Adrian’s onset of GAD?

A) Migraines
B) Divorce
C) Supervisor’s comment about vacation
D) Daily phone calls with her children

Answer: C – Supervisor’s comment

Explanation: Although her GAD began after the divorce, the ambiguous remark by her supervisor triggered a worsening of symptoms, activating fears of incompetence and rejection in her workplace.

Research Note: In GAD, acute stressors often exacerbate chronic worry; intolerance of uncertainty makes ambiguous remarks especially potent triggers.

Supervisor’s Remark as Symptom Flare Precipitant

Which event most directly precipitated Adrian’s recent escalation of GAD symptoms?

A) Migraines
B) Divorce
C) Supervisor’s comment about vacation
D) Daily phone calls with her children

Answer: B) Psychoeducation + self-monitoring

Explanation: Initial sessions focused on education and developing awareness via diaries.

First Treatment Phase

What was the first intervention step in Adrian’s therapy?

A) Behavioral experiments
B) Psychoeducation + self-monitoring
C) Worry exposure
D) Pharmacotherapy

Answer: C) By a behavioral experiment (asking supervisor directly, testing prediction)

Explanation: This tested her catastrophic belief of being fired, leading to disconfirmation.

Supervisor’s Comment

How was the supervisor’s vacation remark addressed in therapy?

A) By ignoring it
B) By increasing work hours
C) By a behavioral experiment (asking supervisor directly, testing prediction)
D) By relaxation only

Answer: B) Her children being killed in an accident

Explanation: She confronted her worst feared outcomes, holding the image, then challenging it.

Worry Exposure

Which content was used in Adrian’s imaginal exposure exercises?

A) Supervisor’s promotion
B) Her children being killed in an accident
C) Public speaking
D) Divorce court

Answer: C) Excessive reassurance calls to children

Explanation: She practiced limiting calls, tolerating uncertainty, reducing anxiety maintenance.

Perpetuating Behaviors

What perpetuating safety behavior was reduced during therapy?

A) Coffee drinking
B) Social withdrawal
C) Excessive reassurance calls to children
D) Migraine medication

Answer: B) Continued worry scheduling + homework exposures

Explanation: Structured relapse prevention kept skills active and reduced risk of recurrence.

Relapse Prevention

What was emphasized during the final treatment phase to maintain gains?

A) Avoiding all stressors
B) Continued worry scheduling + homework exposures
C) Stopping self-monitoring immediately
D) Weekly reassurance sessions

Answer: C) Motivation, insight, and good work record

Explanation: Her willingness to engage with therapy enhanced outcomes.

Protective Factor

Which protective factor most supported Adrian’s progress?

A) Denial of symptoms
B) History of divorce
C) Motivation, insight, and good work record
D) Avoiding exposure

Treatment Implementation

1. Early Sessions

   • Psychoeducation: nature of worry & anxiety.

   • Self-monitoring diary (anxiety, depression, triggers, % of day spent worrying).

2. Middle Sessions

   • Cognitive therapy: identify overestimation & catastrophic thoughts.

   • Behavioral experiments (clarifying supervisor’s remark, reducing children’s calls).

3. Later Sessions

   • Worry exposure (imaginal exposure to feared outcomes).

   • Building tolerance for uncertainty.

   • Relapse prevention: homework, continued worry scheduling.

Life Events & 4Ps

• Predisposing factors:

  • Temperamentally anxious, strong responsibility for others.

  • History of migraines (possible biological vulnerability).

• Precipitating factors:

  • Divorce → increased sense of rejection, relational insecurity.

  • Supervisor’s remark about vacation → immediate trigger for catastrophic thinking (“I’ll be fired”).

• Perpetuating factors:

  • Excessive checking on children.

  • Avoidance of clarification at work.

  • Cognitive style: probability overestimation + catastrophizing.

• Protective factors:

  • Insight, motivation for therapy.

  • Good work performance history.

  • Support from children.

3- Gradual Onset and Lifelong Nature.

• GAD often starts in childhood with a temperament of high behavioral inhibition or neuroticism.

• Suggests an enduring personality vulnerability rather than an acute, episodic illness.

• Likely involves a mix of genetic predisposition, early learning experiences, and chronic cognitive style (habitual worry as a coping attempt).

1- Differentiating Normal vs. Pathological Worry (DSM-5).

• Normal worry: Occasional, specific, manageable, does not impair functioning.

• GAD worry: Excessive, uncontrollable, persistent for ≥6 months, about multiple domains, and causes distress or impairment.

——————————————————————————————-

2- Adaptive vs. Maladaptive Worry.

• Adaptive qualities: Helps prepare for challenges, motivates planning, may prevent careless mistakes.

• Maladaptive in GAD: Becomes uncontrollable, consumes time/energy, leads to avoidance, maintains anxiety, and reinforces false beliefs (e.g., Adrian believing arriving early prevents mistakes).

5- Medication – Benzodiazepines

• Short-term effectiveness

• Cognitive/motor impairment risks

• Dependence/tolerance risk

6- Medication – Antidepressants (SSRIs/SNRIs)

• Better long-term outcome than benzodiazepines

• Biological mechanism explained (serotonin, norepinephrine)

• Combination with CBT

7- Biological Mechanisms

• GABA enhancement (benzos)

• Prefrontal-amygdala dysregulation in GAD

8- Psychoeducation

• Relapse risk

• Importance of CBT skills beyond medication

• Realistic expectations for patients

1. Prevalence & epidemiology

   • Lifetime prevalence (1.9–5.7%)

   • National Comorbidity Survey data

   • 2:1 female-to-male ratio

   • Elderly prevalence (7–10%)

   • Use of tranquilizers in older adults

2. Comorbidity

   • High rates of co-occurrence with mood and other anxiety disorders

   • 80–90% with another disorder

3. Onset & Course

   • Early adulthood / adolescence

   • Often gradual and lifelong anxiety

4. Impairment & Burden

   • 82% reported impairment (treatment-seeking, lifestyle interference)

   • GAD not “mild” compared to other anxiety disorders