Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-745bb68f8f-lrblm Total loading time: 0 Render date: 2025-02-10T20:12:28.983Z Has data issue: false hasContentIssue false

23 - Treating Complexity and Comorbidity in Anxiety Disorders and Depression

from Part Five - Complexity and Comorbidity in Anxiety Disorders and Depression:

Published online by Cambridge University Press:  06 January 2022

By
Cory F. Newman
Edited by
Gillian Todd  and
Rhena Branch
Gillian Todd
Affiliation:
University of East Anglia
Rhena Branch
Affiliation:
University of East Anglia
Get access

Summary

An effective, parsimonious way to treat patients who present with comorbid conditions and other complexities is to use process-based, generic CBT employing case conceptualization. This approach allows therapists to assess and target the patient’s maladaptive processes in functioning that may underlie several areas of diagnostic concern, and whose remediation may produce multiple clinical benefits. The case conceptualization serves as a road map to understand the patient’s subjective phenomenology, thus facilitating well-targeted interventions and abetting the therapeutic relationship. The case of Zina demonstrates how the patient’s avoidance strategies and maladaptive schemas played roles in her mood disorder (with suicidality), anxiety, eating disorder, substance use, and purging – and how all of these interfered with her life goals. The therapist prioritized Zina’s safety and attended closely to the therapeutic relationship. The case conceptualization helped illuminate ways to enhance Zina’s participation in treatment (including pharmacotherapy). Eighty sessions produced positive results.

Keywords

complexitycomorbidityconceptualizationgeneric CBTprocess-basedsafety plansuicidalitytherapeutic relationship
Type
Chapter
Information
Evidence-Based Treatment for Anxiety Disorders and Depression
A Cognitive Behavioral Therapy Compendium
 , pp. 475 - 504
Publisher: Cambridge University Press
Print publication year: 2022

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Recommended Reading

Barlow, D. H., Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Allen, L. B., & Ehrenreich-May, J. T. (2011). Unified protocol for transdiagnostic treatment of emotional disorders. Oxford University Press.Google Scholar
Hayes, S. C., & Hoffman, S. G. (2018). Process-based CBT: The science and core clinical competencies of cognitive behavioral therapy. New Harbinger Publications.Google Scholar
Kazantzis, N., Dattilio, F. M., & Dobson, K. S. (2017). The therapeutic relationship in cognitive behavior therapy: A clinician’s guide to the heart and soul of effective practice. Guilford Press.Google Scholar
Kuyken, W., Padesky, C. A., & Dudley, R. (2009). Collaborative case conceptualization: Working effectively with clients in cognitive-behavioral therapy. Guilford.Google Scholar
Zilcha-Mano, S. (2017). Is the alliance really therapeutic? Revisiting this question in light of recent methodological advances. American Psychologist, 72, 311–325.CrossRefGoogle Scholar

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of the mental disorders (5th ed.). American Psychiatric Association.Google Scholar
Arch, J. J. (2018). A conversation with Steve Hayes and Stefan Hofmann about process-based CBT. The Behavior Therapist, 41, 81–83.Google Scholar
Barlow, D. H., Farchione, T. J., Bullis, J. R., Gallagher, M. W., Murray-Latin, H., Sauer-Zavala, S., … & Casiello-Robbins, C. (2017). The Unified Protocol for transdiagnostic treatment of emotional disorders compared with diagnostic-specific protocols for anxiety disorders: A randomized clinical trial. Journal of the American Medical Association, 74, 875–884.Google Scholar
Barlow, D. H., Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Allen, L. B., & Ehrenreich-May, J. T. (2011). Unified protocol for transdiagnostic treatment of emotional disorders. Oxford University Press.Google Scholar
Beck, A. T., Butler, A. C., Brown, G. K., Dahlsgaard, K. K., Newman, C. F., & Beck, J. S. (2001). Dysfunctional beliefs discriminate personality disorders. Behaviour Research and Therapy, 39, 1213–1225.Google Scholar
Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893–897.Google Scholar
Beck, A. T., Freeman, A., Davis, D., et al. (2004). Cognitive therapy of personality disorders (2nd ed.). Guilford.Google Scholar
Beck, A. T., & Haigh, E. A. P. (2014). Advances in cognitive theory and therapy: The generic cognitive model. Annual Review of Clinical Psychology, 10, 1–24.Google Scholar
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory II. Psychological Corporation.Google Scholar
Beck, A. T., Weissman, A., Lester, D., & Trexler, L. (1974). The measurement of pessimism: The Hopelessness Scale. Journal of Consulting and Clinical Psychology, 42, 499–505.CrossRefGoogle ScholarPubMed
Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). Guilford Press.Google Scholar
Cameron, S. K., Rodgers, J., & Dagnan, D. (2018). The relationship between the therapeutic alliance and clinical outcomes in cognitive behavior therapy for adults with depression: A meta-analytic review. Clinical Psychology and Psychotherapy, 25, 446–456.CrossRefGoogle ScholarPubMed
Chapman, A. L., & Rosenthal, Z. M. (2016). How to confront therapy-interfering behavior. In Chapman, A. L. & Rosenthal, Z. M. (Eds.), Strategies from dialectical behavior therapy (pp. 145–165). American Psychological Association.Google Scholar
Clark, D. A., & Beck, A. T. (2010). Cognitive therapy of anxiety disorders: Science and practice. Guilford.Google Scholar
Comtois, K. A., & Landes, S. J. (2018). Crisis management and treating suicidality from a behavioral perspective. In Hayes, S. C. & Hofmann, S. G. (Eds.), Process-based CBT: The science and core clinical competencies of cognitive behavioral therapy (pp. 415–425). New Harbinger Publications.Google Scholar
Cummings, J. A., Hayes, A. M., Newman, C. F., & Beck, A. T. (2011). Navigating therapeutic alliance ruptures in cognitive therapy for avoidant and obsessive-compulsive personality disorders and comorbid Axis-I disorders. International Journal of Cognitive Therapy, 4, 397–414.Google Scholar
Dahlsgaard, K. K., Beck, A. T., & Brown, G. K. (1998). Inadequate response to therapy as a predictor of suicide. Suicide and Life-Threatening Behavior, 28, 197–204.Google Scholar
Dobson, D., & Dobson, K. S. (2009). Evidence-based practice of cognitive-behavioral therapy. Guilford.Google Scholar
Dudley, R., Kuyken, W., & Padesky, C. A. (2011). Disorder specific and trans-diagnostic case conceptualization. Clinical Psychology Review, 31, 213–224.Google Scholar
Easden, M. H., & Kazantzis, N. (2018). Case conceptualization research in cognitive behavior therapy: A state of the science review. Journal of Clinical Psychology, 74, 356–384.Google Scholar
Ellard, K. K., Bernstein, E. E., Hearing, C., Baek, J. H., Sylvia, L. G., Nierenberg, A. A., … & Deckersbach, T. (2017). Transdiagnostic treatment of bipolar disorder and comorbid anxiety using the Unified Protocol for Emotional Disorders: A pilot feasibility and acceptability trial. Journal of Affective Disorders, 219, 209–221.Google Scholar
Ellard, K. K., Deckersbach, T., Sylvia, L. G., Nierenberg, A. A., & Barlow, D. H. (2012). Transdiagnostic treatment of bipolar disorder and comorbid anxiety with the unified protocol. A clinical replication series. Behavior Modification, 36, 482–508.Google Scholar
Eubanks, C. F., Burckell, L. A., & Goldfried, M. R. (2018). Clinical consensus strategies to repair ruptures in the therapeutic alliance. Journal of Psychotherapy Integration, 28, 60–76.Google Scholar
Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Thompson-Hollands, J., Carl, J. R., … & Barlow, D. H. (2012). Unified Protocol for transdiagnostic treatment of emotional disorders: A randomized controlled trial. Behavior Therapy, 43, 666–678.Google Scholar
First, M. B., Williams, J. B., Karg, R. S., & Spitzer, R. L. (2016). User’s guide for the SCID-5- CV Structured Clinical Interview for DSM-5 disorders: Clinical version. American Psychiatric Publishing.Google Scholar
Haarhoff, B. A., Flett, R. A., & Gibson, K. L. (2011). Evaluating the content and quality of cognitive behavioral therapy case conceptualizations. New Zealand Journal of Psychology, 40, 104–113.Google Scholar
Hayes, S. C., & Hofmann, S. G. (2018). Process-based CBT: The science and core clinical competencies of cognitive behavioral therapy. New Harbinger Publications.Google Scholar
Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36, 223–233.Google Scholar
Kidney, R., & Kuyken, W. (2014). Collaborative case conceptualization: Three principles and five steps for working with complex cases. In Whittington, A. & Grey, N. (Eds.), How to become a more effective CBT therapist: Mastering metacompetence in clinical practice (pp. 83–103). Wiley-Blackwell.Google Scholar
Kuyken, W., Padesky, C. A., & Dudley, R. (2009). Collaborative case conceptualization: Working effectively with clients in cognitive-behavioral therapy. Guilford.Google Scholar
Lam, D. H., Hayward, P., Watkins, E., Wright, K., & Sham, P. (2005). Relapse prevention in patients with bipolar disorder: Cognitive therapy outcome after two years. American Journal of Psychiatry, 162, 324–329.Google Scholar
Lam, D. H., Wright, K., & Sham, P. (2005). Sense of hyper-positive self and response to cognitive therapy in bipolar disorder. Psychological Medicine, 35, 69–77.CrossRefGoogle ScholarPubMed
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.Google Scholar
Mansell, W., Harvey, A., Watkins, E., & Shafran, R. (2009). Conceptual foundations of the transdiagnostic approach to CBT. Journal of Cognitive Psychotherapy: An International Quarterly, 23, 6–19.Google Scholar
Merikangas, K. R., & Kalaydjian, A. (2007). Magnitude and impact of comorbidity of mental disorders from epidemiologic surveys. Current Opinion in Psychiatry, 20, 353–358.Google Scholar
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, 487–495.CrossRefGoogle ScholarPubMed
Miklowitz, D. J., Otto, M. W., Frank, E., Reilly-Harrington, N. A., Wisniewski, S. R., Kogan, J. N., … & Sachs, G. S. (2007). Psychosocial treatments for bipolar depression: A 1-year randomized trial from the Systematic Treatment Enhancement Program. Archives of General Psychiatry, 64, 419–427.Google Scholar
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). Guilford Press.Google Scholar
Muran, J. C., Safran, J. D., Eubanks, C. F., & Gorman, B. S. (2018). The effect of alliance-focused training on a cognitive-behavioral therapy for personality disorders. Journal of Consulting and Clinical Psychology, 86, 384–397.Google Scholar
Newman, C. F. (2004). Substance abuse. In Leahy, R. L. (Ed.), Contemporary cognitive therapy: Theory, research, and practice (pp. 206–227). Guilford Press.Google Scholar
Newman, C. F. (2007). The therapeutic relationship in cognitive therapy with difficult-to-engage clients. In Gilbert, P. & Leahy, R. L. (Eds.), The therapeutic relationship in the cognitive-behavioral psychotherapies (pp. 165–184). Routledge-Brunner.Google Scholar
Newman, C. F. (2008) Substance use disorders. In Whisman, M. A. (Ed.), Adapting cognitive therapy for depression: Managing complexity and comorbidity (pp. 233–254). Guilford Press.Google Scholar
Newman, C. F. (2011). When clients’ morbid avoidance and chronic anger impede their response to cognitive-behavioral therapy for depression. Cognitive and Behavioral Practice, 18, 350–361.Google Scholar
Newman, C. F. (2015). Cognitive restructuring/cognitive therapy. In Nezu, A. M. & Nezu, C. M. (Eds.), Oxford handbook of cognitive and behavioral therapies (pp. 118–141). Oxford University Press.Google Scholar
Newman, C. F., & Kaplan, D. A. (2016). Supervision essentials for cognitive-behavioral therapy. American Psychological Association.Google Scholar
Newman, C. F., & Strauss, J. S. (2003). When clients are untruthful: Implications for the therapeutic alliance, case conceptualization, and intervention. Journal of Cognitive Psychotherapy: An International Quarterly, 17, 241–252.CrossRefGoogle Scholar
Norcross, J. C., & Lambert, M. J. (2011). Psychotherapy relationships that work II. Psychotherapy, 48, 4–8.Google Scholar
Norton, P. J., & Paulus, D. J. (2016). Toward a unified treatment for emotional disorders: Update on the science and practice. Behavior Therapy, 47, 854–868.Google Scholar
O’Donohue, W. O., Fowler, K. A., & Lilienfeld, S. O. (2007). Personality disorders: Toward the DSM-V. Sage.Google Scholar
Perry, A., Tarrier, N., Morriss, R., McCarthy, E., & Limb, K. (1999). Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. British Medical Journal, 318, 139–153.Google Scholar
Persons, J. B., Beckner, V. L., & Tompkins, M. A. (2013). Testing case formulation hypotheses in psychotherapy: Two case examples. Cognitive and Behavioral Practice, 20, 399–409.CrossRefGoogle Scholar
Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48, 80–87.CrossRefGoogle ScholarPubMed
Safran, J. D., Muran, J. C., & Shaker, A. (2014). Research on therapeutic impasses and ruptures in the therapeutic alliance. Contemporary Psychoanalysis, 50, 211–232.Google Scholar
Schmidt, N. B., Joiner, T. E. Jr., Young, J. E., & Telch, M. J. (1995). The Schema Questionnaire: Investigation of psychometric properties and the hierarchical structure of a measure of maladaptive schemata. Cognitive Therapy and Research, 19, 295–321.Google Scholar
Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19, 256–264.CrossRefGoogle Scholar
Strakowski, S. M. (2014). Bipolar disorder. Oxford University Press.Google Scholar
Strauss, J. L., Hayes, A. M., Johnson, S. L., Newman, C. F., Barber, J. P., Brown, G. K., … & Beck, A. T. (2006). Early alliance, alliance ruptures, and symptom change in cognitive therapy for avoidant and obsessive-compulsive personality disorders. Journal of Consulting and Clinical Psychology, 74, 337–345.Google Scholar
Tee, J., & Kazantzis, N. (2011). Collaborative empiricism in cognitive therapy: A definition and theory for the relationship construct. Clinical Psychology: Science & Practice, 18, 48–62.Google Scholar
Waltman, S. H., & Sokol, L. (2017). The generic model of cognitive behavioral therapy: A case conceptualization-driven approach. In Hofmann, S. G. & Asmundson, G. J. G. (Eds.), The science of cognitive behavioral therapy (pp. 3–17). Elsevier Academic Press.Google Scholar
Wenzel, A., Brown, G. K., & Beck, A. T. (2009). Cognitive therapy for suicidal clients: Scientific and clinical applications. American Psychological Association.Google Scholar
Whisman, M. A. (2008). Adapting cognitive therapy for depression: Managing complexity and comorbidity. Guilford.Google Scholar
Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. Guilford.Google Scholar
Young, R. C., Biggs, J. T., Ziegler, V. E., & Meyer, D. A. (1978). A rating scale for mania: Reliability, validity, and sensitivity. British Journal of Psychiatry, 133, 429–435.CrossRefGoogle ScholarPubMed
Zilcha-Mano, S. (2017). Is the alliance really therapeutic? Revisiting this question in light of recent methodological advances. American Psychologist, 72, 311–325.Google Scholar
Zilcha-Mano, S., Muran, J. C., Hungr, C., Eubanks, C. F., Safran, J. D., & Winston, A. (2016). The relationship between alliance and outcome: Analysis of a two-person perspective on alliance and session outcome. Journal of Consulting and Clinical Psychology, 84, 484–496.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×