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Guildford BABCP conference: symposium on cognitive factors that maintain GAD and worry (second post)

First day of the conference proper.  I wrote yesterday about the pre-conference "Workshop on couples therapy with Don Baucom" that I went to.  It was excellent and I intend to write more about it later.  For now though, the conference.  9.00 to 11.15am and already we have a choice of 18 different symposia, skills classes, panel discussions and clinical roundtables.  Gosh.  I go for a symposium on "Cognitive factors that maintain GAD and worry".  There are four talks in the symposium.  The first is on "Cognitive factors that maintain worry: The role of imagery and verbal processing of feared and benign worry outcomes."  Interesting stuff ... especially as the outcome wasn't what I would have expected (and possibly not what the researchers would have expected either).  It was a "laboratory" analogue study, as so many studies are that are presented at these conferences.  It's important to treat outcomes from this kind of work with plenty of caution when considering whether to begin applying these findings clinically.  The paper's abstract comments " ... Participants were ... trained to engage in either imagery or verbal processing whilst thinking about either the feared outcome of the worry topic, or a benign outcome of the worry topic (depending on group allocation).  Participants then focused on their outcome in the specified mentation style for three blocks of two minutes. They then completed the breathing focus task again. ... Thinking in verbal form about the feared outcome perpetuated negative thoughts intrusions, but thinking in imagery about the feared outcome, or thinking about the benign outcome (whether in verbal or imagery form) led to a reduction in negative intrusions." 

I find this interesting, especially as the graphs shown by the lecturer actually demonstrated the lowest subsequent intrusions for verbally processing a benign outcome of the worry.  Worry is such a (negative) verbal process that I would have expected the imagery conditions to have come out ahead of even a positive verbal processing group.  And for imagery, positive processing of a benign outcome was as helpful in reducing subsequent intrusions as negative imagery processing.  I think this could be useful clinically.  The 2002 Nelson & Harvey study "The differential functions of imagery and verbal thought in insomnia" reported that "Individuals with insomnia were exposed to a stressor (speech threat) prior to getting into bed and were instructed to think about the speech and its implications in either images ... or verbal thought ... In the short term, the Image group reported more distress and arousal relative to those in the Verbal group.  In the longer term, the Image group estimated that they fell asleep more quickly and, the following morning, reported less anxiety and more comfort about giving the speech compared with the Verbal group."  In the light of today's talk it seems a reasonable - although tentative - strategy to encourage worriers, like these insomnia sufferers, to start with positive verbal processing of their worry.  An obvious option would be to encourage "reappraisal" emotional regulation strategies - see the post "Reappraising reappraisal" or Barlow's simpler variant on this described in "Unified protocol - emotional awareness & cognitive reappraisal" with its focus just on challenging overestimation of occurence probability and severity.  It's worth noting that "affect labeling" also seems to reduce the intensity of negative (and positive) emotional responses - see the recent paper "Subjective responses to emotional stimuli during labeling, reappraisal, and distraction."  One could also add in ideas from the pretty rapidly accumulating literature on positive emotional focus (in imagery & in writing) illustrated by last year's conference post "Disagreeing with Jamie Pennebaker - writing can be used with positive experiences too".  Mm ... interesting.  More classic imagery processing of feared worry outcomes is likely to be less pleasant to do and can be kept as a third, fall-back option. 

The second talk was on "Worry in imagery and verbal form: Effect on residual working memory capacity."  They reported "High (but not low) worriers had less available working memory capacity when worrying in verbal compared to imagery-based form ... The findings indicate that the verbal nature of worry is implicated in the depletion of working memory resources during worry among high-worriers, and point to the potential value of imagery-based techniques in cognitive behavioural treatments for problematic worry."  We were also reminded that this tendency for high worriers to struggle more with depleted working memory capacity suggests that, as therapists, it may help for us to be cautious over what we expect our high worrying clients to remember from their sessions.  Yet another reason to record sessions and suggest that clients then listen to these recordings before we next meet - see more on this on the "Introduction & monitoring" page of this website.  There are no doubt connections, as well, to the recently reported finding that subjective memory complaints in the middle-aged are much more strongly related to psychological state than to vascular problems - see "Subjective memory complaints, vascular risk factors and psychological distress in the middle-aged: a cross-sectional study" with its conclusion that " ... clinicians should be vigilant regarding the presence of an affective illness when assessing middle-aged patients presenting with memory problems."

Next up was a presentation on "Intolerance of uncertainty, worry and obsessive-compulsive symptoms: Common and specific features."  The paper's abstract reads "Intolerance of Uncertainty (IU) is a construct that has proven to be useful in the understanding and treatment of anxiety disorders, especially GAD and OCD ... Despite the increasing popularity of the constructs and their measures, a number of conceptual and measurement issues have been identified. These include definition itself, the nature of the core features of IU, any differential features in GAD and OCD, specificity or not to OCD/GAD, its status as a transdiagnostic feature, etc.  Based on our ongoing reconceptualisation of the construct, we have developed a framework for examining the similarities and differences between IU in GAD and OCD.  This presentation presents some initial data examining specificity or not of certain key features of the construct in accounting for variance in measures of worry and OCD symptoms."  Interesting stuff.  Mark Freeston's developing model of "front end" threat orientation IU processes (more typical of GAD) and "back end" solution orientation IU processes (more typical of OCD) looks as though it has the potential to evolve into something of some clinical use ... watch this space ... hopefully the Newcastle team will be back at this conference next year reporting on a further step forward in this investigation. 

The fourth and last talk of this symposium was on "Ten years of published research on mood-as-input and perseverative worrying: Implications for GAD" with its abstract stating "We review 10 years of published evidence from laboratory-based analogue studies of mood-as-input effects and perseverative worrying.  As predicted by mood-as-input theory, worriers deploy ‘as many as can' rather than ‘feel like continuing' stop rules during negative mood, which leads to perseveration on a worry catastrophizing task.  The deployment of ‘as many as can' stop rules is significantly related to worry frequency as measured by the PSWQ and is closely linked to the more stable beliefs that worriers have about the nature of worrying.  Worriers do not appear to possess an iterative style that is independent of the stop rule they adopt, and their perseveration can be significantly modified under experimental conditions by changing the type of stop rule they deploy."  OK.  The big disappointment is that after 10 years of laboratory research, the value of these ideas still hasn't been tested clinically.  It might well be that teaching high worriers to more often adopt non-as-many-as-can stop rules could be of some help.  It reminds me of Tom Borkovec's intervention with GAD sufferers, where he asked them to stop worrying episodes during the day as much as possible with the reminder that they were going to take specific time-limited "worry time" once daily (often in the evening). 

Now time for one of the conference's first plenary lectures - I chose Anke Ehlers on "Cognitive therapy for PTSD: an update"

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