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318. However, in this and other studies, it seems that lack of effectiveness may be due to a cessation of the CBT and not due to its lack of effectiveness while in treatment (Belleville, 2011, p. 318). Regardless, there are very few, if any, studies that show evidence of negative effects of CBT.
An additional factor that should be taken into account in Isabella's case is that substance use may be involved. Neither the DSM nor the DASS questionnaires address the theory that substance use may exacerbate or may be premorbid to anxiety/depression/stress disorders. Perhaps additional questionnaire(s) regarding substance use should have been presented to her. The Cannabis Expectancy Questionnaire is an example of a questionnaire that directly addresses substance use by assessing use by the patient (Connor, 2010).
An important additional consideration regarding Isabella's case is that in her verbal report she states that her inability to relax and her indecisiveness are have been detrimental to her well-being. It is unclear whether the diagnosis of insomnia and its associated treatment will help her sense of well-being. Any treatment that helps Isabella sleep better may help her to relax in waking hours as well as help her make decisions, but such treatments may not help, or help very little.
According to many models of psychopathology, simply addressing Isabella's insomnia and not her other symptoms is not an ideal treatment. Psychoanalytic models claim the cause of pathology is unresolved conflict, and any treatment must involve insight into the reasons behind conflict. Cognitive and behavioral models claim that negative, learned thinking and behavioral responses are a source of problems, and treatment involves new ways of thinking and learning. Finally, humanistic models claim that problems are largely due to incomplete self-actualization, which is treated with empathy and positivity. All of these models, when applied to Isabella's case, would seem to require treatment in addition to simply treating her insomnia. Specifically, these theories of psychopathology call for psychotherapy. Even if presently Isabella's case is mild, it is possible that it will become more severe over time, and preventative measures now may prove to be cost-effective (and effective for Isabella's well-being) over the long run (Kessler, 2003, p. 1117).
An additional theory regarding anxiety as it relates to Isabella's case warrants discussion. It has been theorized that worrying about worrying (meta-worry), and the holding of positive beliefs about the usefulness of worrying, is a feature of GAD (Wells, 1999, p. 585). Isabella seems to hold positive beliefs about the usefulness of her worrying, as in her verbal report she mentions that she believes her worrying has helped her do well academically and that her worrying is useful for helping her cope. According to Wells and Carter (Wells, 1999, p.585), this meta-worry can lead to an increase in the frequency and generality of worrying, and to pathological worry and anxiety. This pattern in Isabella is additional evidence that she should possibly be diagnosed with GAD, not just insomnia, and that additional treatments may be useful for her.
In summary, this essay has argued that Isabella, who presented to her GP with concerns about her sleep and stress levels, may need an additional diagnosis and treatments than that recommended by her GP. This is because of limitations of the DASS questionnaire she completed, incomplete information from her verbal report, and the possibility of her having GAD. A less likely diagnosis than GAD is MDD/dysthymia, but this possibility should not be ruled out.
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