Psychotherapy for Generalized Anxiety...

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Chapter 14

Psychotherapy for Generalized Anxiety DisorderJonathan D. Huppert, Ph.D.William C. Sanderson, Ph.D.

AUTHOR: 1) Below are affiliations for each chapter authoras they will appear in the contributor list in the front of thebook. Please review these carefully and provide any miss-ing information or updates. (This information will bemoved to the front matter to create an alphabetical list ofcontributors at the next stage of production.)

2) So that we may send each contributor a complimentarycopy of the book on publication, please update currentmailing information for each author (what we have on fileis listed below). UPS requires a street address (not a P.O.box) and a phone number.

Jonathan D. Huppert, Ph.D.Associate Professor of Psychology, The Hebrew Univer-sity of Jerusalem, Mt. Scopus, Jerusalem, Israel

UPS – Jonathan D. Huppert, Ph.D., [author: is this mail-ing address sufficient?] Department of Psychology, HebrewUniversity of Jerusalem, ISRAEL; tel.: 02-588-3376; fax:02-588-1159; e-mail: [email protected]

William C. Sanderson, Ph.D.Professor of Psychology, Hofstra University, Hempstead,New York

UPS – William C. Sanderson, Ph.D., Department of Psy-chology, Rutgers University, Piscataway, NJ 08854;tel.:__________ (please provide); e-mail: [email protected]

As discussed in other chapters in this volume, gener-alized anxiety disorder (GAD) is a relatively commondisorder that is associated with significant distress andfunctional impairment. Recent advances in both phar-macotherapy and psychotherapy have resulted in agreater likelihood of providing effective treatment.However, reports suggest that people with GAD re-spond less robustly compared with those who haveother anxiety disorders, which highlights the need forcontinued work in understanding the nature and treat-ment of GAD. In this chapter, we provide an overviewof empirically based psychotherapeutic treatment ofGAD. First, we briefly describe the history of psycho-social approaches to GAD, which have been predomi-

254 TEXTBOOK OF ANXIETY DISORDERS

nantly cognitive-behavioral. Next, we elucidate the psy-chological mechanisms associated with GAD thatappear to be involved in the maintenance of the disorderand, thus, must be addressed in treatment. We thenprovide a review of the treatment outcome literature rel-evant to GAD, and briefly review how treatment hasbeen applied to special populations such as children andolder adults. Finally, an overview of empirically sup-ported psychological treatment strategies is provided.This chapter ends with a treatment algorithm to suggestwhat techniques to use and when to use them.

The Nature of Generalized Anxiety DisorderGAD is a relatively new diagnosis, transformed from a“wastebasket” diagnosis pertaining to anyone with anx-iety whose symptoms did not meet criteria for any otheranxiety disorder listed in DSM-III (American Psychi-atric Association 1980) to an independent diagnosis,more “carved at its joints” in DSM-III-R and DSM-IV(American Psychiatric Association 1987, 1994) (seealso Chapter 11, “Phenomenology of Generalized Anx-iety Disorder,” in this volume). Until the advent ofDSM-III-R in 1987, the development of treatment forGAD was aimed at treating “anxious neurotics.” Twoprimary techniques were utilized: relaxation or biofeed-back to address physiological tension and arousal (Riceand Blanchard 1982), and cognitive therapy to addressthe anxious thoughts associated with GAD (Beck1976). Most CBT treatment protocols developed sincethen continue to integrate these two major strategies.However, as a result of greater precision in the defini-tion of GAD and an increased understanding of the na-ture of worry and anxiety (Heimberg et al. 2004), newertreatment protocols also include strategies to addressthese recently identified components (e.g., techniquesto minimize experiential avoidance, techniques to en-hance problem solving).

WorryThe diagnosis of GAD depends on the existence of twocore symptoms: worry (i.e., preoccupation with negativeevents occurring in the future) and physiological hyper-arousal (e.g., muscle tension, sleep disturbance, feelingkeyed up). Clearly, worry is frequently the most prom-inent symptom of GAD and is considered the cardinalfeature of the disorder. Worry is a cognitive activity of-ten referred to as anxious apprehension. It is elicited by

the perception of potential future danger (Craske 2003)such as “What if I fail the licensing exam I am takingnext week and as a result I am not able to get a job?”Worry is often accompanied by behavior directed atgaining control to avoid the occurrence of the negativeevent (Rapee 1991; e.g., “What can I do to prevent fail-ing the exam?”). Indeed, the appropriate “function” ofworry will lead one to take action to decrease the likeli-hood of potential negative outcomes (e.g., increasestudying to avoid failing the exam), thereby decreasingthe anxiety.

Although worry in itself is not pathological, and is infact very common in the population at large, individualsdiagnosed with GAD suffer from excessive worry; thatis, reporting worry most of the day, nearly every day(Brown et al. 1993; Dupuy et al. 2001). Even thoughworry often activates attempts at problem solving innearly everyone, individuals with GAD lack confidencein their solutions, thereby leading to continued worry(Davey 1994). This raises an important issue to con-sider: if worry is a ubiquitous experience, how does itdiffer in individuals with GAD versus those without thedisorder? There are two main aspects of pathologicalworry that differentiate it from “normal” worry (de-scriptive studies such as Ruscio and Borkovec 2004 andinformation-processing studies such as Mathews 1990provide supportive evidence). First, pathological worryappears to be uncontrollable. In a study by Abel andBorkovec (1995), all (100%) of the patients with GADdescribed their worry as uncontrollable, in comparisonwith none of the control subjects. Second, pathologicalworry is excessive for a given situation, in that patientsoverestimate the threat in their environment, especiallywhen interpreting ambiguous cues (Mathews 1990). Infact, these two features may be the result of GAD pa-tients’ intolerance of uncertainty, leading to more exces-sive and uncontrollable worry (Dugas et al. 1998). Inaddition, anxious subjects tend to selectively attend tothreatening, personally relevant stimuli (Mathews1990). The overprediction of danger may lead patientswith GAD to worry more often than others becausethey perceive their environment as more threatening.Frequently, the implied belief is that worry will makethe world more controllable and predictable. For exam-ple, one patient stated, “When I fly in an airplane, Iworry that the plane will crash. If I stopped worryingabout it, it probably would crash.” Consistent with thisfeature, worriers report five major functions of worry:1) superstitious avoidance of catastrophes, 2) actualavoidance of catastrophes, 3) avoidance of deeper emo-

Psychotherapy for Generalized Anxiety Disorder 255

tional topics, 4) coping preparation, and 5) motivatingdevices (Borkovec 1994).

Research has demonstrated that pathological worryhas a functional role for patients with GAD. Ironically,worry inhibits autonomic arousal in patients with GADwhen they are shown aversive imagery (Borkovec andHu 1990). Worrying may allow for the avoidance ofaversive imagery, the latter being associated with agreater emotional state (Borkovec et al. 1991). Thus,worry may be maintained by both the avoidance of cer-tain affective states and the reduction of anxious statesthrough the decrease in arousal that occurs along withworry (see Borkovec et al. 2004 for a review). Counter-intuitively, relaxation has been shown to increase theamount of worry in some patients with GAD (Borkovecet al. 1991). In these patients, relaxation may signal alack of control, triggering an increase in anxiety, or thesepatients may sit quietly with their thoughts, causinggreater exposure to their worries.

In addition, individuals with GAD often have aheightened sense of the likelihood of negative events(i.e., increased risk perception) and often exaggerate thenegative consequences that would occur (Brown et al.1993). Patients with GAD and control subjects appearto worry about similar topics (Sanderson and Barlow1990), although patients with GAD tend to worry morefrequently about minor matters (Brown et al. 1994).Spheres of worry endorsed by patients with GAD in-clude concerns about family, health, social matters, fi-nances, work, and world events. The topics of worrymay change with age and life situation.

Physiological HyperarousalIn addition to worry, patients with GAD experience un-pleasant somatic sensations associated with physiologi-cal hyperarousal. The presence of physiological arousalis seen as a component of the “fight-or-flight” responsethat is activated by GAD patients’ perceptions of dan-ger. Although both the cognitive and the somatic sen-sations usually increase during the course of a “worryepisode,” for the most part, these symptoms are rela-tively chronic, and not limited to episodes of worry. Themost common somatic symptom reported by patientswith GAD is muscle tension. Other common symp-toms include irritability, restlessness, feeling keyed up oron edge, difficulty sleeping, fatigue, and difficulty con-centrating.

Characteristics of Patients With Generalized Anxiety DisorderGAD is a relatively chronic disorder that begins inchildhood (Brown et al. 1994). In view of these andother similar data, some argue that, in contrast to otheranxiety disorders, a subtype of GAD (chronic, pervasivesymptoms since childhood) may be better conceptual-ized as an underlying personality trait that increasesone’s vulnerability to developing anxiety disorders(Sanderson and Wetzler 1991). Along this line, Barlow(2002) considers GAD the “basic anxiety disorder.”GAD-like symptoms typically start in childhood, butoften, a major stressor at some point in the individual’slife will exacerbate symptoms and raise the condition toa clinical disorder. For example, one common exampleof a trigger we see clinically is becoming a parent. It ap-pears that the increased responsibility and desire forperfection in child rearing may exacerbate these traits tothe point of interference and distress.

New conceptualizations of GAD have focused on in-terpersonal deficits that may have developed in child-hood (Crits-Christoph et al. 2005; Newman et al.2004). In fact, interpersonal difficulties and concernsappear to be common triggers for worry episodes. Alongthis line, Sanderson and Barlow (1990) found that themajority of patients with GAD suffer from clinicallysignificant social evaluative concerns. Other recent con-ceptualizations have focused on emotion regulationproblems in individuals with GAD (e.g., Mennin et al.2005). It is likely that the interpersonal and emotionregulation deficits interact to create difficulties (e.g.,Erickson and Newman 2007). Other common charac-teristics of GAD patients include perfectionism, ex-traordinary need for control in their environment, diffi-culty tolerating ambiguity, and feelings of increasedpersonal responsibility for negative events that occur orare predicted to occur in their environment (Wells1994).

AUTHOR: Please provide a full reference to correspond tothe above citation of Erickson and Newman 2007.

Differentiating Generalized Anxiety Disorder From Other DisordersAccurate diagnosis is an essential first step in providingthe appropriate treatment for a particular disorder. Infact, differentiating GAD from other anxiety disorders


can be extremely complicated. First, worry (or anticipa-tory anxiety) is a relatively generic feature of anxiety dis-orders (e.g., patients with panic disorder often worryabout future panic attacks, patients with social anxietydisorder worry about embarrassing themselves in forth-coming social situations). In addition, a high level of co-morbidity exists among the anxiety disorders, andGAD in particular, which requires one to consider di-agnosing multiple disorders to account for the full rangeof psychopathology displayed by the individual (Sand-erson and Wetzler 1991). To do this, the clinician mustdistinguish between symptoms that can be subsumedwithin GAD versus those that are signs of an additional,independent disorder. The primary distinction to bemade in differential diagnosis is not the presence ofworry per se, but the focus of the worry. Patients withGAD experience uncontrollable worry about multipleareas of their life. Common worries include minor mat-ters, work and family responsibilities, money, health,safety, and the well-being of significant others. More-over, patients with GAD often end up worrying abouttheir worry (known as metaworry; Wells 1994). We willreview differential diagnostic considerations below,with an emphasis on the distinctions that are relevant toCBT treatment (see Chapter 11, “Phenomenology ofGeneralized Anxiety Disorder,” for other consider-ations of differential diagnosis).

Panic DisorderPatients with panic disorder are worried about having apanic attack or about the consequences of experiencingcertain bodily sensations. Their focus is on internalstates. What makes the differential diagnosis particu-larly confusing is that the worry experienced by patientswith GAD can lead to a panic attack. However, unlikepatients with panic disorder, patients with GAD areconcerned primarily about some future event, not aboutthe negative consequences of having a panic attack orthe symptoms of anxiety per se. Some patients withGAD focus on the physical symptoms of their anxiety,and this can lead one to think that the preoccupationwith bodily sensations is a sign of panic disorder. How-ever, there is a distinction between distress about thepresence of bodily sensations (e.g., muscle tension) andcatastrophic misinterpretations of such sensations (e.g.,my heart racing means I am having a heart attack). An-other distinction is the course of onset of worry com-pared with that of panic symptoms. The onset of a panicattack is sudden, and its peak typically lasts for several

minutes, whereas the onset and course of GAD-relatedanxiety are usually longer and more stable.

Social Anxiety DisorderSocial concerns are a common area of worry for patientswith GAD, and these patients are often assigned a co-morbid diagnosis of social phobia (Sanderson et al.1990). For diagnosis of GAD, additional concerns be-yond the social evaluative fears must be present. As op-posed to the concerns of individuals with social anxietydisorder, interpersonal concerns in individuals withGAD frequently include interactions with close friendsand relatives (e.g., “Did I say something wrong to mywife?”) and are not as focused on rejection by others spe-cifically because of inadequate content or behaviors (i.e.,saying or doing things that are perceived as strange orunintelligent). In contrast to patients with social anxietydisorder, the evaluative concerns of patients with GADextend beyond fears of embarrassment. In addition, pa-tients with GAD are less likely than patients with socialanxiety disorder to engage in significant avoidance, ei-ther overt (e.g., not going to parties, not meeting newpeople, not talking to people) or social anxiety-specific(e.g., censoring one’s thoughts, staying on the edge ofgroups, rehearsing sentences in one’s mind beforespeaking) which are focused on the prevention of nega-tive evaluations and embarrassment.

AUTHOR: Above: 1) For clarity, should social anxiety dis-order be identified as another term for social phobia? Oruse one or the other throughout?

2) Sentence beginning “In addition,…” was missing aword. To fix, “significant overt avoidance” has beenchanged to “significant avoidance, either overt” Correct?

Obsessive-Compulsive DisorderAlthough the differentiation between obsessive-com-pulsive disorder (OCD) and GAD seems obvious be-cause of the behavioral rituals that are unique to OCD(Brown et al. 1994), some cases still can be extremelydifficult to differentiate. This is especially true of pa-tients with OCD who do not have overt compulsions(i.e., have only mental rituals). In these cases, a distinc-tion must be made between the obsessions and the wor-ries. To do so, it is necessary to assess the focus of con-cern. The nature of obsessions tends to be unrealisticand often takes an “if-then” form (e.g., “If I don’t cancelthe thought that my child will be hurt in a car accident


by imagining him safe at home, then he will be in a caraccident”). In contrast, worry associated with GAD isusually focused on future negative events that are poten-tially more realistic; and it is more likely to be specifiedin a “what if ” fashion, without a consequence beingstated (e.g., “What if I am in a car accident on the high-way and my children are injured?” or “What if I becomeill?”). In research examining the distinction, nonanxioussubjects reported that worry lasts longer and is moredistracting (Wells and Morrison 1994). Worry also usu-ally takes the form of predominantly verbal thoughts asopposed to images (Wells and Morrison 1994). Al-though compulsive behaviors are associated with OCD,patients with GAD often engage in reassurance-seek-ing and checking behaviors that can be somewhat ritu-alistic and superstitious (i.e., similar to compulsive be-havior; Schut et al. 2001). In addition, patients withGAD may report feeling compelled to act to neutralizetheir worries (Wells and Morrison 1994; e.g., to callone’s wife at work to lessen a worry about somethinghappening to her). However, these behaviors are not asconsistent, methodical, or ritualized as compulsive be-haviors in patients with obsessive-compulsive disorder.

Mood DisordersA differentiation must also be made between GAD andmood disorders, especially major depression and dys-thymia. According to DSM-IV-TR, if GAD symptomsare present only during the course of a depressive epi-sode, then GAD is not diagnosed as a comorbid disor-der. More often than not, anxiety symptoms occurwithin the context of depression; thus, GAD is diag-nosed as a separate disorder only when the symptomshave occurred at least at some point independent of de-pression. However, regardless of DSM exclusionary cri-teria, the nature of cognitions associated with each dis-order can be distinguished: ruminations (common indepressive disorders) tend to be negative thought pat-terns about past events, whereas worries (associatedwith GAD) tend to be negative thought patterns aboutfuture events. This is consistent with theoretical con-ceptualizations of anxiety and depression, which positthat depression is a reaction to uncontrollable, inescap-able negative events, leading to feelings of hopelessnessand helplessness and deactivation, whereas anxiety is areaction to uncontrollable negative events that the per-son attempts or plans to escape from (for a more de-tailed explanation, see Barlow 2002). The high comor-bidity rates, symptom overlap, and genetic similaritiesbetween GAD and depressive disorders (see Huppert,

in press, for a review) support the notion that GAD anddepression may have a common underlying predisposi-tion. In fact, it has been suggested that GAD be movedinto a category of dysphoric disorders in DSM-V andnot be included among the anxiety disorders (Watson2005).

AUTHOR: Above: 1) Please update press status of Hup-pert reference above.

2) In sentence beginning “According to DSM-IV-TR,” “thenGAD” has been substituted for “then it,” to clarify. Pleaseconfirm this is correct.

Review of Treatment Outcome StudiesIn our previous review of GAD (Huppert and Sander-son 2002), we reviewed meta-analyses and studies con-ducted between 1987 and 2000. Since 2000, several re-views have been written about the treatment of GAD(Borkovec and Ruscio 2001; Covin et al. 2008; Gould etal. 2004; Hunot et al. 2007; Mitte 2005; Roemer et al.2002; Rygh and Sanderson 2004; Siev and Chambless2007; Westen and Morrison 2001). As in earlier re-views, the efficacy of cognitive-behavioral therapy(CBT) and related strategies (e.g., cognitive restructur-ing, relaxation training) has received the most support-ive evidence when used to alleviate worry and anxiety. Infact, the Task Force of the Division of Clinical Psychol-ogy of the American Psychological Association, whichis involved with identifying empirically supported treat-ments, found that the only psychosocial treatment withsufficient research support to be labeled “empiricallysupported treatment” is CBT (Chambless et al. 1998;Woody and Sanderson 1998). Independent reviews oftreatments for GAD by the National Institute for Clin-ical Excellence in the United Kingdom (McIntosh et al.2004) and by the International Consensus Group onAnxiety and Depression (Ballenger et al. 2001) con-cluded that CBT is equivalent to medication as a first-line treatment. Furthermore, Dutch guidelines fortreatment of anxiety by primary care physicians also rec-ommend CBT (van Boeijen et al. 2005). These treat-ment recommendations are based on the accumulatedliterature demonstrating the efficacy of CBT for GADas well as support for the cost-effectiveness of suchtreatments (Heuzenroeder et al. 2004). Although thereis some preliminary evidence suggesting short-term


psychodynamic treatments for anxiety disorders may beeffective (Crits-Christoph et al. 2005; Ferrero et al.2007), adequate controlled studies have yet to be con-ducted. Therefore, consistent with the empirical litera-ture, our review emphasizes CBT.

Previous ReviewsBorkovec and Ruscio (2001) conducted a meta-analysisof treatment outcome studies for GAD. Their primaryconclusion was that CBT for patients with GAD ismore efficacious in treating both anxious and depressivesymptoms than no treatment or nonspecific controlconditions, and that the combination of cognitive andbehavioral strategies tends to be better than eitheralone. Specifically, they reported large between-groupeffect sizes for acute CBT when compared with notreatment, medium effect sizes when compared withplacebo or alternative therapies, and small effect sizeswhen compared with cognitive or behavioral therapyalone. Nonspecific treatments (e.g., supportive psycho-therapy) were reported to have large within-group effectsizes, but smaller than CBT. Long-term follow-up sug-gested smaller, but sustained, advantages of CBT overother treatments. Similar conclusions about the efficacyof CBT for GAD were reported by Gould et al. (2004).However, in their review, Hunot et al. (2007) concludedthat it is difficult to determine whether CBT is substan-tially more effective than supportive therapy. A meta-analysis by Mitte (2005) in which CBT was comparedto medications revealed that overall, CBT was superiorto no treatment or placebo control conditions and wassimilar in effectiveness to medications. However, fur-ther analyses suggested that medications for GAD maybe somewhat more effective than CBT, even thoughCBT may be more tolerable than medications (based onlower dropout rates). In her conclusions, Mitte statedthat it is clear CBT for GAD has specific treatment ef-fects beyond common factors. Most reviews concludethat approximately 50% of patients receiving CBT arecategorized as responders.

AUTHOR: Above, “Long-term follow-up suggested...”:Please clarify how this report of a follow-up finding relatesto the 2001 meta-analysis of many studies by Borkovecand Ruscio, and provide a reference and citation if neces-sary. Thanks.

Newer Studies As shown in Table 14–1, during the period 2000–2007,17 outcome studies on GAD were published. A few ofthese studies presented follow-up data to previouslyconducted trials; most included CBT and at least oneother treatment group, a minimum of a 6-month fol-low-up assessment, and a variety of outcome measures,usually a combination of self-report and clinician-ratedmeasures. For Table 14–1, we calculated percentage im-provement in anxiety and worry by subtracting post-treatment averages from pretreatment averages andthen dividing by the pretreatment averages. Data weregathered from information provided in the publishedreports. Self-report and clinician-rated measures wereseparated, because each type of information can be sub-stantially different (i.e., a clinician may see improve-ment when a patient does not, or vice versa). Whetherauthors noted improvement, no change, or relapse dur-ing follow-up periods is noted next in the table. Finally,the rate of dropout is presented in the last column. Notethat many percentages of improvement were calculatedby using treatment-completer analyses; these resultscould have been substantially different if intent-to-treatanalyses had been used. We do not review each studyhere because many of them are included in the previousdiscussion of meta-analytic reviews.

AUTHOR: In sentence above beginning “Note that manypercentages,” please check edited version to ensure itkeeps the intended meaning.

Table 14–1 is currently at the end of the chapter. It will bepositioned about here at a later phase of production.

The 17 studies can be divided into numerous catego-ries: studies examining the efficacy of CBT versus wait-list conditions, dismantling designs that examinedrelaxation versus cognitive therapy (and/or their combi-nation), studies attempting to improve CBT outcomesby adding other techniques, and studies examining psy-chodynamic therapies. Some of these studies also pro-vided analyses to determine predictors of treatmentoutcome, which will be discussed later. Studies varied interms of the length of treatment sessions employed andin the number of treatment sessions included. As in ourreview of studies that were published during the 1990s(Huppert and Sanderson 2002), percentage of improve-ment was rated consistently greater by “blind” clinicians


than by patients’ self-reports. According to indepen-dent evaluators, CBT yielded from 30% to 66% im-provement in anxiety, and self-report measures yieldedbetween 11% and 61% improvement. With regard tofollow-up, all but one study revealed no significantchanges (either deterioration or improvement) fromposttreatment to follow-up. However, one study didshow statistically significant continued improvementafter acute treatment (i.e., improvement from posttreat-ment to follow-up). With regard to comparisons withother treatments, overall, CBT was seen as significantlymore effective than the waitlist control condition, andresults for those who received CBT after being in thewaitlist group showed they improved similarly to thosewho initially received CBT (Bowman et al. 1997;Ladouceur et al. 2000). Dismantling studies found thatcognitive therapy, relaxation, and their combinationyielded similar effect sizes (see also Siev and Chambless2007).

AUTHOR: Above, in last sentence, “dismantling studies”:Please clarify this phrase (or define this term).

To date, attempts to improve outcome by adding ormodifying techniques have yielded variable results, withsome findings showing more promise than others.Durham et al. (1994, 2004) have examined longer- ver-sus shorter-duration CBT, with mixed findings.Durham et al. (1994) suggested that 16 sessions of CBTmay be more effective than 8 sessions. However, in asecond study in which patients were a priori categorizedinto those likely to have good versus poor outcome,Durham et al. (2004) found that providing more CBT(20 vs. 10 sessions) to individuals predicted to have pooroutcome did not improve outcomes. In contrast, pro-viding short-duration CBT (6 sessions) to individualspredicted to have good outcomes worked quite well(equivalent to those receiving more sessions, in thegroup predicted to have poor outcomes), and improve-ment continued at follow-up (see Table 14–1). Bork-ovec et al. (2002) modified typical CBT by including 2-hour sessions for all conditions. Although they foundsomewhat larger effect-sizes compared with other stud-ies using this treatment in the short run (at posttreat-ment), the results were not substantially better than pre-vious findings at follow-up. As a result of this study andtheir clinical experiences, Borkovec et al. (2002) sug-gested the need to examine alternative strategies toCBT, such as addition of interpersonal and emotion-fo-

cused techniques, rather than just an increase in theamount of CBT. Indeed, Newman et al. (2008) have re-cently completed a trial of CBT alone compared with anintegrated CBT plus interpersonal and emotion-fo-cused therapy. Preliminary results suggest that CBTalone was as effective as the integrated treatment atposttreatment and at 1-year follow-up. However, for asubgroup of patients, advantages of the integrated treat-ment in anxiety symptom reduction at 2-year follow-upemerged (Newman et al. 2008).

At present, perhaps the area receiving the greatestamount of attention within the CBT field is the incor-poration of mindfulness meditation and acceptance-basedtechniques into, or instead of, standard CBT approaches.These techniques have been examined in the treatmentof GAD as well. Unfortunately, preliminary resultsfrom initial trials in which the outcomes are comparedwith other CBT trials have not supported the notionthat these strategies provide an additional benefit. Theinclusion of mindfulness and acceptance-based tech-niques (Evans et al. 2008; Roemer and Orsillo 2007)does not appear to enhance the efficacy of CBT forGAD (see Table 14–1).

Two therapeutic strategies that appear to be promis-ing additions to CBT are the addition of well-being ex-ercises (i.e., focusing on improving quality of life andpositive aspects of one’s life; cf. Fava et al. 2005) andmeta-cognitive therapy (i.e., focusing specifically onpositive and negative beliefs about worry, thought con-trol strategies, and other techniques; Wells and King2006). Table 14–1 provides more details of these andother studies modifying CBT.

Three studies have examined the efficacy of psycho-dynamic treatments for GAD. Although two of thesestudies are predominantly nonrandomized trials, thefact that they include psychodynamic treatment, whichis a commonly utilized approach in clinical practice,merits their extensive consideration. Therefore, moredetails about these studies are described, although thisshould not be seen as an endorsement of these tech-niques over CBT approaches that have been studiedmore extensively. Each study used a different school ofpsychodynamic thought (psychoanalytic/classicalFreudian, neo-Freudian interpersonal, Adlerian).Durham et al. (1994, 1999, 2003) were the only inves-tigators to examine both cognitive and psychodynamictherapies for GAD. Crits-Christoph et al. (1996) con-ducted an open trial examining the effects of short-termpsychodynamic therapy for GAD, for which 1-year fol-low-up data are available (Crits-Christoph et al. 2004).


The group also published a randomized trial, suggestingthat nondirective, supportive therapy was equally as ef-fective as their psychodynamic approach (Crits-Chris-toph et al. 2005). They presented their data in a com-bined sample. In addition, Ferrero et al. (2007) reportedon a trial of short-term Adlerian psychodynamic ther-apy. Each of the treatments yielded improvements insymptoms, although the degree of improvement dif-fered.

AUTHOR: Please review edits to sentence above begin-ning “Therefore, more details.” OK?

Durham et al. (1994) compared cognitive therapy(Beck et al. 1985) to anxiety management (a behavioraltechnique) and to psychoanalytic therapy. A total of 110patients with GAD were divided into five groups: 1)brief CBT (average of 9 sessions), 2) extended CBT(average of 14 sessions), 3) brief analytic therapy (aver-age of 8 sessions), 4) extended analytic therapy (averageof 16 sessions), and 5) anxiety management training(average of 8 sessions). Results of this study indicatedthat patients who received any form of CBT improvedmost and those who received psychoanalytic psycho-therapy improved least, with the group receiving anxietymanagement showing levels of improvement some-where in between. Patients who received psychoanalytictreatment deteriorated on three measures (although notsignificantly), whereas patients in the CBT groups im-proved on all measures at posttreatment and 6-monthfollow-up, and the anxiety management group main-tained gains. Follow-up data revealed that patients con-tinued to improve after CBT or anxiety managementwas terminated. Follow-up data at 1 year and 8–10 yearshave been published (Durham et al. 1999, 2003). At1 year, CBT continued to show superiority to psycho-analytic therapy in terms of symptom reduction, re-sponse rates, and overall functioning, and there weresome advantages found for more intensive CBT overfewer sessions. Anxiety management continued to be abit less effective than CBT and more effective than psy-choanalytic therapy. At the 8–10-year follow-up, manydifferences between CBT and psychoanalytic treatmenton anxiety and response measures had disappeared,though functioning and global symptom measures con-tinued to indicate CBT was superior. It is interesting tonote that a greater number of patients who received psy-choanalytic therapy sought further treatment betweenthe posttreatment and follow-up assessments.

AUTHOR: In above sentence beginning “Results of thisstudy indicated...”: Change OK?

This study had several strengths. First, the authorsmeasured patients’ expectancies of recovery throughtherapy, which showed that patients in both CBT andrelaxation training had greater expectations of improve-ment than did those in the psychoanalytic groups afterthe third treatment session. In addition, they used well-trained therapists who were strong believers in their re-spective theoretical perspectives, thus eliminating ex-perimental bias (allegiance effects) for any one treat-ment. However, the study had several weaknesses aswell. The researchers did not conduct adherence orcompetency ratings to ensure that the therapists in factprovided the said treatment components. In addition,few therapists were used in the study and, as a result, itwas possible that some of the treatment differencescould have been due to therapist differences.

Crits-Christoph et al. (1996, 2004, 2005) conductedan open clinical trial and a small randomized trial of ashort-term psychodynamically oriented treatment forGAD called supportive-expressive psychodynamictherapy (SEP). The authors used treatment manuals,adherence ratings, and therapists carefully trained in apsychodynamic treatment to target problems specifi-cally thought to arise in GAD. SEP is grounded in psy-chodynamic theory, positing that anxiety is related toconflictual interpersonal attachment patterns and in-complete processing of past traumatic events. The treat-ment focused on conflicts in relationships through ex-amining the interpersonal desires of the patient(wishes), reactions of others to these desires, and conse-quences of these reactions. Relationships explored in-cluded current and past relationships, as well as thetherapeutic relationship. In SEP, the proposed mecha-nism of change is through working with the patient onexploring alternative methods of coping with feelingsand interpersonal conflicts. SEP orients the therapist todeal with specific GAD-oriented wishes, mechanismsof defense, and resistances. In addition, the influence oftermination on the patient is explored in depth.

A total of 61 patients with GAD (diagnosed bystructured interview) were treated by therapists trainedin SEP (Crits-Christoph et al. 2005). Posttreatmentmeasures indicated significant improvement in all areas.There was less change in specific areas of interpersonalfunctioning (dominant and overly nurturing styles)than expected. Overall, effect sizes were similar to those


calculated for CBT and nondirective psychotherapy. Asubset of these patients was part of an unpublished ran-domized trail comparing SEP with nondirective sup-portive therapy (see Borkovec and Abel 1991, in whichCBT was superior to the same treatment). No differ-ences in outcome were found on continuous measures.However, the quality of the response among patients re-ceiving SEP was better than among those receiving thenondirective therapy (i.e., more were considered to beremitters), and the variability of response was less.Thus, preliminary data suggest that this new, innovativepsychodynamic therapy may be effective for patientswith GAD, and is certainly worthy of further investiga-tion.

AUTHOR: Please provide a full reference to correspond toabove citation of Borkovec and Abel 1991.

Another psychodynamic approach, Adlerian psy-chodynamic therapy (APT), was examined in a clinicaltrial by Ferrero et al. (2007). Patients with GAD wereassigned to either APT, medication management, orthe combination, based on clinical judgment of whatwas best for the patient by the treating psychiatrist. Re-sults suggested that all three conditions were effective,although the percentage of improvement was somewhatlower than in CBT treatment trials. Given the lack ofrandom assignment, it is difficult to make firm conclu-sions from this study. However, it appeared that APTwas quite effective in reducing anxiety and depressionand improving quality of life. In addition, there was nodifference in outcome in the APT condition for thosewith Axis II disorders and those without, whereas formedication treatment, there appeared to be poorer re-sponse among patients with Axis II disorders. Overall,the results complement the findings of Crits-Christophet al. (2005), demonstrating that short-term dynamictherapy focused on interpersonal issues can be thera-peutic for individuals with GAD. Clearly, more re-search is needed on these psychodynamic treatments,especially controlled trials, as well as investigation intothe mechanism of action of psychodynamic treatmentand whether or not it differs from that of CBT (Ablonand Jones 2002).

Effect of Comorbidity on Outcome of Generalized Anxiety DisorderGiven the high rate of comorbidity in GAD (Sandersonand Barlow 1990), it is important to determine the im-

pact of additional diagnoses on treatment outcome. Al-though many of the treatment studies described abovehave included patients with a variety of comorbid diag-noses, only four published studies have specifically ex-amined the effect of comorbid disorders on the treat-ment of GAD. Borkovec et al. (1995) found thatcomorbid anxiety disorders tended to remit when treat-ment focused on GAD. Of 55 patients with a principaldiagnosis of GAD, 23 (41.8%) were rated as having atleast one clinically significant comorbid Axis I diagnosis(patients with major depression had been ruled out ofthe study, thus decreasing the overall rate of comorbid-ity). At a 12-month follow-up, only two patients re-tained a clinically significant comorbid diagnosis, sug-gesting that in most cases, comorbid anxiety disordersmay not need to be addressed directly. This may belargely a result of the fact that the treatment for GADmay be useful in reducing other anxiety symptoms aswell. For example, learning cognitive restructuring asapplied to worry in GAD may ultimately be generalizedby the patient and used for coping with other anxietysymptoms. Ladouceur et al. (2000) reported that theirsample of 26 patients included individuals with multiplecomorbid diagnoses—most commonly, specific phobiaand social phobia. At pretreatment, patients had an av-erage of 1.6 additional diagnoses, whereas at posttreat-ment and follow-up, they had significantly fewer (an av-erage of 0.4) additional diagnoses.

Sanderson et al. (1994) examined the influence ofpersonality disorders on outcome in an open trial andfound that CBT treatment effects were equivalent forGAD patients with and without personality disorders.However, patients with personality disorders were morelikely to drop out of treatment. A total of 32 patientswith diagnoses of GAD were separated into two groups,based on whether or not they had a concurrent person-ality disorder. Of the 32 patients, 16 were diagnosedwith a personality disorder and 16 without. Of the 10dropouts (those not receiving what was defined as aminimal dose of treatment), 7 were given a diagnosis ofa personality disorder at the pretreatment evaluation.Effect sizes of treatment completers in both groupswere similar to those mentioned by Borkovec and Rus-cio (2001). In light of these data, it appears that atten-tion should be paid to issues related to dropout in pa-tients with personality disorders (e.g., difficultiesforming therapeutic relationships, which is a consistenttheme in a subgroup of GAD patients, as noted above).

Analogous to the finding in the Borkovec et al.(1995) study, a number of studies have focused on


changes in comorbidity rates in treated patients withprincipal diagnoses of panic disorder. Brown et al.(1995) reported that GAD remitted when the focus oftreatment was on the principal diagnosis of panic disor-der in patients with a comorbid diagnosis of GAD. Of126 patients with panic disorder, 32.5% received an ad-ditional diagnosis of GAD. Comorbidity did not appearto influence completer status, but did appear to influ-ence initial severity of panic (i.e., those with a comorbiddisorder had more severe panic disorder). Of the 57 pa-tients available for follow-up analyses, 26.3% were givendiagnoses of GAD at pretreatment, whereas only 7.0%were given such diagnoses at posttreatment, 8.8% at 3-month follow-up, and 8.8% at 24-month follow-up.Thus, 11 of 15 (73.3%) patients did not meet criteria fora clinical diagnosis of GAD at posttreatment, and gainswere maintained throughout follow-up assessments.Similar findings have been found by Tsao and col-leagues in three studies (2005). Once again, consideringthat the strategies used in CBT for panic disorder aresimilar to those used for GAD, it is not surprising thatthe treatment would generalize to other anxiety symp-toms as well (Sanderson and McGinn 1997).

Predictors of OutcomeDurham and colleagues (2004) have been the most sys-tematic in examining predictors of treatment outcome.In two studies, they found that predictors of poor out-come include greater initial severity, low socioeconomicstatus, comorbidity, history of previous treatment, andrelationship difficulties. The last is consistent withstudies by Borkovec et al. (2002) and Zinbarg et al.(2007), both of which found pretreatment interpersonalstyle or hostile communication patterns with partners tobe predictive of treatment outcome. In addition,Durham et al. (2004) found that the therapeutic alliancewas a good predictor of acute outcome but a much lesssignificant predictor of long-term outcome.

AUTHOR: In first sentence above, please provide a con-text for “have been the most systematic” (among allresearchers of GAD? or among all whose studies arereviewed in this chapter?), or change wording (e.g., “...have been highly systematic...”)

Special Populations

Older AdultsAlthough controversy exists as to whether or not thetypical onset of GAD tends to be earlier versus later inlife (Barlow 2002), it is safe to say that a significant per-centage of older adults (i.e., >age 60 years), perhaps ashigh as 7% of the population, suffer from GAD (Flint1994). Given that the vast majority of treatment trialson GAD examine considerably younger subjects (infact, some exclude individuals over age 65), it cannot beassumed that the effectiveness of treatment found inthose trials applies to older adults. Thus, a body of re-search has emerged examining the efficacy of CBT, asdescribed above, for GAD in older adults (e.g., Stanleyet al. 1996, 2003___; Wetherell et al. 2003). Clearly, thetreatment with the most consistent support for late-lifeGAD is CBT (Ayers et al. 2007), with approximatelyhalf of patients achieving a significant improvement(Wetherell et al. 2005). Although these results arepromising, it is important to note that, overall, re-sponder rates in studies of GAD in older adults havebeen somewhat lower than those reported in the litera-ture on younger adults (Stanley et al. 2003___). In lightof this finding, a study by Mohlman et al. (2003) is par-ticularly interesting. In a preliminary, uncontrolledstudy, they tested an “enhanced version” of CBT that in-cluded learning and memory aids designed to make thetherapy more effective for elderly patients (e.g., home-work reminder and troubleshooting calls) and found itto be superior to standard CBT. Investigating this mod-ification in controlled trials is certainly warranted, andmay eliminate the gap between response rates inyounger and older adults suffering from GAD.

AUTHOR: Please see reference list and identify the twoStanley et al. 2003 citations above as 2003a or 2003b.

ChildrenAlthough there are no studies examining the efficacy ofCBT in an exclusive sample of children diagnosed withGAD, several trials have evaluated CBT on mixed sam-ples, often including children with GAD, overanxiousdisorders, and social anxiety disorder. For example, alarge study by Kendall et al. (2004) included 94 childrenwho had an anxiety disorder—55 of whom were diag-nosed with GAD. Data revealed significant improve-ment in anxiety symptoms from pretreatment to post-treatment. In a thorough review of the literature on


CBT for childhood anxiety disorders, Chorpita andSoutham-Gerow (2006) concluded that CBT has “verystrong empirical support” for childhood GAD. It isworth noting that although the treatment closely re-sembles the intervention package utilized for adults(i.e., it includes cognitive and behavioral components),the child intervention by Kendall (1990), labeled theCoping Cat Program, has been modified to be morechild-friendly.

CBT Techniques for Generalized Anxiety DisorderAs should be clear by now, CBT is the only psychother-apeutic approach with strong empirical support fromcontrolled research studies. Although there may besome subtle differences in treatment packages employedwithin these studies, for the most part, there are severalcommon “essential” elements contained in almost everyCBT manual for GAD. (For detailed descriptions ofthese techniques, see: Rygh and Sanderson 2004; Zin-barg et al. 2006.) These methods include psychoeduca-tion, self-monitoring, cognitive restructuring, relax-ation, worry exposure, worry behavior control, andproblem solving. Of course, these techniques should bedelivered in the context of a good psychotherapeutic at-mosphere that includes all of the nonspecific effects oftherapy (e.g., a good therapeutic relationship, positiveexpectancy, warmth). Each technique is briefly de-scribed below.

PsychoeducationAs in most cognitive-behavioral treatments, psychoed-ucation about GAD is an important aspect of therapy.Several rationales exist for starting treatment with edu-cation about anxiety and worry. First, we believe thatknowledge is an important factor in change. Many pa-tients who have come in for treatment have never beentold their diagnosis and frequently have misconceptionsabout their disorder (e.g., that anxiety will lead to psy-chosis) and misunderstandings about common re-sponses (e.g., physiological, emotional) to worry andstress (e.g., that all worry is bad or that increased heartrate means that you are more likely to have a heart at-tack). In addition, some patients want a greater under-standing of why they are anxious and what they can doabout it. So, the first step in CBT treatment is educatingpatients about the biopsychosocial model of anxiety(Rygh and Sanderson 2004; Borkovec et al. 2004).

Many patients experience great relief in knowing thattheir experiences are not uncommon, that a consider-able amount of scientific knowledge exists about the eti-ology and phenomenology of GAD, and that effectivetreatments designed specifically for their difficulties areavailable. Finally, providing education about GAD is away to review the treatment rationale (i.e., what thepurpose of each treatment strategy is) and thus may fa-cilitate treatment compliance.

We recommend that psychoeducation be providedfirst in a written form (e.g., via a Web site on GAD suchas the one available through the National Institute ofMental Health (http://www.nimh.nih.gov/health/topics/generalized-anxiety-disorder-gad/index.shtml) and thenfollowed up in session. During the session, questions areanswered and the information is reviewed in a mannerthat makes the information personally relevant to thepatient.

Self-MonitoringSelf-monitoring is one of the most basic yet essentialparts of CBT. Monitoring is used as both an assessmentprocedure (to identify the context and content of worry)and a treatment strategy. (Becoming aware of patternsand focusing on worry and anxiety may lead to reduc-tion in worry and anxiety.) The basic concept of moni-toring is that each time the patient feels worried or anx-ious, he or she should record when and where theanxiety began and the intensity of the experience, in-cluding symptoms that were present. The patient canmonitor his or her experience on a full sheet of paperthat describes the entire week or record one situation orday at a time. The amount of information gathered mayvary with each patient, according to each individual’sabilities and needs. It should be noted that avoidance ofmonitoring is seen as detrimental to treatment, becauseof the likelihood that the patient is avoiding anxiety.Thus, we prefer to simplify and problem-solve to attaincompliance rather than eliminate the monitoring alto-gether.

To enhance compliance, the therapist should informthe patient of the reasoning behind the monitoring: tohelp elicit specific patterns that occur and lead to worryepisodes, to obtain a good estimate of current symp-toms, to be able to notice effects of treatment on symp-toms, and to further examine worry (e.g., cognitions,behaviors). The basic aspects of worry monitoring aredate, time began, time ended, place, event (trigger), av-erage anxiety (from 1 [minimal] to 8 [extremely dis-tressing]), peak anxiety (1–8), average depression (1–8),


and topics of worry. Once cognitive restructuring is in-troduced, monitoring the specific thought process in-volving worries is added.

Cognitive Therapy: Restructuring the WorryAs stated earlier, worry is a predominantly cognitiveprocess, thereby making cognition an important aspectto address. Cognitive therapy is an effective strategy forthis purpose. Patients with anxiety disorders, and withGAD in particular, overestimate the likelihood of neg-ative events and underestimate their ability to cope withdifficult situations (A.T. Beck et al. 1985). These “cog-nitive distortions” can play a major role in the viciouscycle of anxiety, and they accentuate the patient’s feel-ings of danger and threat. Thus, cognitive therapy tar-gets the faulty appraisal system and attempts to guidethe patient toward more realistic, logical thinking.

The idea of cognition and its influence on anxiety arereviewed with the patient in the introduction to therapyand the psychoeducation discussion. Threadedthroughout the biopsychosocial model is the theme thatcognition plays a major role in eliciting and perpetuat-ing the cycle of anxiety. Cognitive restructuring is intro-duced in detail by discussing the concepts of automaticthoughts, anxious predictions, and the maintenance ofanxiety through unchallenged/unchecked negative pre-dictions about the future.

AUTHOR: Above, note change from “Threaded . . . is thefact that . . .”: (One doesn’t usually think of a “fact” as“threaded.”) Change OK?

Automatic thoughts are described as learned responsesto cues that can occur so quickly that they may be out-side of one’s awareness. However, these cognitions cancreate, maintain, and escalate anxiety if their contentcontains information with a danger-related theme.Thus, the patient is taught to observe his or her ownthoughts at the moment of anxiety (or immediately af-ter), to assess what cues may have brought on the feel-ing, and to elaborate on what thoughts were goingthrough his or her mind. The goal is to bring thethoughts into awareness. Initially, the thoughts are notimmediately challenged but collected as data to deter-mine common thoughts that occur during worry. In ad-dition to self-monitoring during anxiety episodes, anx-ious cognitions are accessed within the therapy sessionthrough Socratic questioning (asking questions to lead

the patient to uncover his or her thoughts during anxi-ety-provoking situations), role-playing (if worry oc-curred during a social interaction, playing the role of thefriend and replaying the event in the session), and im-agery (trying to visualize a worry-provoking event to ac-cess thoughts and fears). Increases in levels of anxietyeither in or outside of the session are opportune times tomonitor “hot” cognitions. This often needs to be mod-eled by filling out a thought record and helping the pa-tient elicit thoughts (e.g., “I won’t be able to do thehomework right”) in session before patients can accu-rately monitor their thoughts for homework. It is oftenhelpful to warn patients that monitoring thoughts canprovoke anxiety because one is focusing on anxious cog-nitions. It should be explained that exposure to suchthoughts, while uncomfortable, is necessary for change.

Once thoughts have been monitored sufficiently todetermine frequency and themes, categories of distortedthinking are introduced. Several cognitive distortionshave been identified as common in patients with GAD,the three most common being probability overestima-tion, catastrophizing, and all-or-none (black-and-white) thinking (A.T. Beck et al. 1985; Brown et al.1993).

Frequently, many distortions exist within one state-ment. In our clinical experience, it can be very helpful toaddress all of the distortions in each statement. This willhelp the patient have a fully loaded armamentariumagainst anxious thoughts. A patient may remain anxiousafter challenging a thought-focus on a single type ofdistortion because he or she is still apprehensive aboutanother distortion. Thus, we believe that the most ef-fective strategy is to thoroughly process all cognitivedistortions. For example, a patient presents with a worrystatement that he is not going to be able to pay the renton time because he thinks that his paycheck will come inthe mail late. We would have the patient evaluate theprobability that he will not pay the rent, based on pastexperiences of receiving his paycheck, evaluate the con-sequences of his paying the rent late, and evaluate hisbelief that if he is 1-day late with the rent, it is as if hewill never pay it. Thus, the one worry may contain allthree categories of distortions. Challenging in this fash-ion focuses on automatic thoughts. This may be suffi-cient for some patients, but for others it may be neces-sary to examine core beliefs (i.e., consistent thoughtpatterns about oneself, the environment, or the future;J.S. Beck 1995).


RelaxationRelaxation exercises are an important component ofmost CBT-oriented treatments for GAD. The functionof these exercises is to reduce the physiological corre-lates of worry and anxiety by lowering the patient’soverall arousal level. Relaxation reduces arousal, but itmay play other roles as well. First, it may help broadenthe focus of one’s attention; anxiety tends to narrow at-tentional focus (Barlow et al. 1996). As a result of itsanxiety-reducing property, relaxation may widen thescope of attention and thereby increase the patient’sability to consider alternatives in an anxiety-provokingsituation. In addition, relaxation may serve as a distrac-tion. Distraction is not effective as a sole method, be-cause by constantly avoiding anxious cognitions, thepatient is subtly supporting the belief that his or herthoughts are threatening and/or harmful. However, dis-traction can be an effective tool when the GAD patientis “stuck” in a worry pattern and needs to break the per-severating thoughts. Finally, contrary to the conceptsdescribed above and to conventional wisdom, which as-sumes that relaxation is solely a coping strategy, relax-ation may at times facilitate the activation of anxiousthoughts that are otherwise not being processed (Bork-ovec and Whisman 1996), thereby assisting in exposureto the anxious thoughts. This may explain why somepatients describe becoming more anxious when initiallyengaging in relaxation exercises. Specifically, worryingprevents the processing of other, more fearful informa-tion (see Borkovec and Hu 1990), and relaxation helpsreduce this “protective” worry and thus may ultimatelyaid in exposure to fearful thoughts, ideas, or images thatwere not fully processed through or evoked by worrying.

AUTHOR: 1) Please review edited last sentence above toensure that it keeps the intended meaning. OK as edited?

2) Please provide a full reference to correspond to theabove citation of Barlow et al. 1996.

Whether for any of the reasons cited above or forother reasons not discussed here, relaxation clearly helpspatients with GAD. Most recent methods of teachingrelaxation have adapted a flexible concept rather thaninsisting on any particular approach. Thus, althoughprogressive muscle relaxation techniques are empha-sized for most patients and have the most empirical sup-port, if a patient prefers another method and is able touse it effectively, then we recommend continued use of

that strategy. At times, a combination of relaxationtechniques can also be encouraged, depending on theneeds of the patient. Accordingly, yoga, transcendentalor other types of meditation, and tai chi are all accept-able, especially if the patient is already engaged in suchactivities and/or if progressive muscle relaxation doesnot appear effective.

There are several caveats to be noted about conduct-ing progressive muscle relaxation. First, the goal is tohave the patient feel relaxed. Although similar proce-dures are used to help patients with insomnia, the goalhere is not to have the person fall asleep. Second, thisprocedure is similar to those used in initiating a hyp-notic trance; because of this, patients may react to theprocedure with anxiety, fearing a “loss of control.” It isimportant to explain to the patient the difference be-tween hypnosis and relaxation, as used in CBT forGAD, is that in progressive muscle relaxation the focusis on awareness of bodily sensations. Hypnosis has thegoal of distraction to the point of reaching a trance state.This would be counterproductive in treating GAD be-cause, as discussed in this section, these patients are al-ready distracted from aversive states through worry. Ourgoal is facilitated exposure to worry-provoking stimuli,not avoidance.

Worry ExposureAs noted above, the perpetuation of worry in GAD pa-tients may be caused by incomplete processing of theworry, which may be a result of avoiding focusing on theworry itself. Instead of focusing on a worry that will in-crease anxiety in the short run, patients attempt to avoidfully processing the worry through various behaviors(discussed in the next section), as well as through con-stant shifting of worries. For this reason, Brown et al.(1993) described a technique in which patients pur-posely expose themselves to both worry and images as-sociated with the worry for an extended period. Theconcept is to have the patient activate the worst possibleoutcome in order to process it and habituate to the anx-iety associated with it. Habituation of the anxiety is fa-cilitated through cognitive challenging after the patientfocuses on the image for 20–30 minutes. Similar proce-dures (called cognitive exposure) are used to facilitate in-tolerance of uncertainty in the treatment developed byDugas et al. (2003). Borkovec et al. (1983) developed asimilar technique referred to as stimulus control. In thisapproach, patients are asked to postpone worryingwhen it begins to happen, make a list of the worries thatoccur, and then set aside an hour in the evening to focus


exclusively on the worries. This exercise allows for aconcentrated effort to process the worry, and theoreti-cally it will result in habituation to the content of worry,thereby decreasing anxiety and the worry process itself.Even though there are subtle differences between worryexposure and stimulus control, the basic mechanism ofaction may be the same, namely, cognitive processingand habituation. If the function of worry is similar tothat of agoraphobia or compulsions, in that it reducesthe overall anxiety experience in the short run, then re-peated exposure will cause extinction.

AUTHOR: Above: For clarity, can “of the specific worry,” orsimilar language, be added to end of last sentence?

Worry Behavior ControlMany patients who worry may behave in certain ways totry to avoid it. Although it is an aversive experience, un-controllable worry may serve the function of avoidingan even more intolerable experience (i.e., by focusing onthe worry instead of the other experience). Behaviorsthat facilitate the avoidance of the worry itself may thenresult in avoidance of both the anxiety created by worryand the experience avoided through worrying. Accord-ing to this explanation, the patient’s preoccupation withworry distracts him or her from the original source ofthe negative state (e.g., fear, depression). Therefore,eliminating worry behaviors allows the patient to fullyexperience and process the worry.

To prevent worry behaviors, the patient carefullymonitors what he or she does when he or she notices theonset of worry. Both subtle and explicit variants of theseavoidance behaviors are detected through careful mon-itoring, assessment, and questioning. Then, in a tech-nique similar to that of response prevention used in thetreatment of obsessive-compulsive disorder, the patientis asked to refrain from these behaviors and instead touse the techniques described earlier to cope with theworry. If many behaviors are involved, or if the patient istoo anxious to just give up the worry behaviors, hierar-chies are created to assist the patient in systematicallygiving up the behaviors, starting with easier ones andmoving on to more difficult behaviors, making the taskconsiderably less overwhelming (e.g., checking thechild’s forehead once daily to see if he has a fever, thenevery other day, and so on).

Problem SolvingTeaching problem solving is a classic CBT approach formany disorders. Dugas and colleagues (1998, 2003)outline two main problems for individuals with GAD.They suggest that the core problem of GAD is the in-tolerance of uncertainty, and that this has an impact ontwo types of problems that GAD patients face. The firsttype are “unrealistic problems.” These problems cannotbe solved rationally and must be dealt with via worry ex-posure (for example, for a person who continually wor-ries about his or her health, there is no way to rationallyguarantee that the person will never become ill, so ex-posure to the fear is recommended). The second type ofproblem is “catastrophic thinking” about real issues. Forexample, consider a person who worries about losing hisjob because he received some negative feedback on anevaluation. In this case, there are steps that can betaken—a problem-solving approach—to reduce thelikelihood of this negative outcome. Often, GAD pa-tients become so focused on the catastrophic outcomeand on attempting to avoid the anxiety associated withit that they lose their natural ability to problem solve.Therefore, problem solving must be deliberately insti-tuted. Problem solving includes identification of theproblem, goal setting, generation of alternative solu-tions, selection of a solution, and implementation andevaluation. The goal in introducing these steps is notjust to solve the problem being focused on, but to helpthe patient learn better problem-solving skills and learnthat there are often multiple solutions to problems.

AUTHOR: Note changes to last sentence above (Original:“The goal of problem solving is to help the patient learnbetter problem solving skills (not just to solve the problemfocused on), and to learn that there are often multiplesolutions to problems.” OK as edited?

Future DirectionsAs noted in this chapter, the technique of challengingworries through cognitive restructuring, worry expo-sure, and problem solving is not sufficient for all pa-tients with GAD. If we conceptualize worry as a reac-tion generated in order to avoid a more intenseunderlying affective state, then elimination of worrywill be helpful to only those patients who have sufficientcoping skills and strategies to deal with whatever affectthey experience. For example, just as exposure is helpfulin agoraphobia, most cognitive-behavioral treatmentsof panic work by providing coping skills that will be


used instead of avoidance strategies. If some patientswith GAD are avoiding affect (Mennin et al. 2005),then simply eliminating the worry through relaxationand cognitive techniques will not work unless they aretaught other strategies for dealing with the triggers forthe affect. Borkovec et al. (2004) proposed that inter-personal strategies (i.e., Safran and Segal 1990) betested, in addition to cognitive techniques, to determinewhether processing of interpersonal difficulties facili-tates activation and modification of affective structures(Foa and Kozak 1986). In addition, others have sug-gested working more directly on emotion regulationstrategies through CBT techniques (Huppert and Alley2004), emotion-focused therapy techniques (Mennin2004), or acceptance and mindfulness techniques (Ro-emer and Orsillo 2007). Promising research has beenconducted in the area of adding concepts of well-beingand/or approaching valued, positive experiences (Favaet al. 2005).

AUTHOR: In above paragraph, note additions of “thetechnique of” to first sentence and “generated” to secondsentence (both added to avoid possible misreading). OK?

Along these lines, some have suggested applyingschema-focused therapy to those patients who have notresponded to traditional CBT (McGinn et al. 1994).This approach focuses on addressing underlying “earlymaladaptive schemas,” which theoretically influencecurrent symptomatology. Schemas are defined as persis-tent beliefs one develops about the self, based on forma-tive experiences (which are often recurrent). Negative orfaulty interpretations of positive and negative life expe-riences may lead to lifelong cognitive, behavioral, andemotional patterns of interacting with others and theenvironment. Based on our observations of patientswith GAD, we hypothesize that they may have schemasthat include unrelenting standards (the belief that oneneeds to be the best or perfect at everything one does),vulnerability to harm (the belief that the world is a dan-gerous place and one can easily be hurt in it), and emo-tional inhibition (the belief that expressing one’s emo-tions is dangerous to the self or others and must beprevented). We have previously hypothesized that pa-tients who are CBT nonresponders may fit into thecharacterological model of GAD; thus, an approachthat focuses on these core issues may be warranted(McGinn et al. 1994). However, at this point, the idea isbased on our clinical experience and not on research

data. Our recommendation for treating GAD is to be-gin with the standard CBT approach, and then applythe schema-focused approach to those patients whohave not responded.

AUTHOR: In sentence above beginning “We have previ-ously hypothesized,” please clarify what “these coreissues” refers to. Thanks.

Finally, as an overall approach to treatment, astepped-care approach should be further examined. Thebasic idea of a stepped-care approach is to provide treat-ment in “steps,” depending on need. Given the promis-ing outcomes of self-help programs for some patientswith GAD (White 1998a), as well as the benefit ofCBT provided in group format (White 1998b), theseare both reasonable first-line approaches and can be fol-lowed by more intensive CBT methods for those pa-tients who do not respond to the initial intervention.The stepped-care approach highlights the need formore research on modifying standard CBT treatment toaddress treatment-refractory illness (Durham et al.2004). Modification of standard treatment raises notonly the prospect of providing more intensive CBT, butalso the question of whether alternative approaches,such as mindfulness/acceptance-based or psychody-namic approaches, can improve outcome in patientswith CBT-refractory GAD.

AUTHOR: Please review edits to sentence above begin-ning “Modification of standard treatment raises...” OK asedited?

ConclusionConsiderable progress has been made in understandingthe nature and treatment of GAD, especially given thatGAD only became an independent Axis I disorder in1987. In fact, this progress is largely a result of the con-tinued refinement of the diagnosis from DSM-III toDSM-III-R and, more recently, DSM-IV, in whichGAD went from a residual disorder to an independentdisorder with worry advanced as its cardinal feature.With a focus on the nature and function of worry, clin-ical researchers have been able to develop treatmentsthat specifically target the putative underlying psycho-pathological mechanisms. Demonstrating the processof developing empirically derived treatments, investiga-tors have not been satisfied with treatment results from


standard CBT packages (which appear to help approx-imately 50% of patients), and though unsuccessful todate in finding strategies to significantly improve CBTtreatment, they continue to develop and test new strat-

egies. These continuing research efforts suggest a prom-ising future in the treatment of GAD.

AUTHOR: Last two sentences above OK as edited?

Key Clinical Points• Substantial evidence suggests that cognitive-behavioral therapy for generalized

anxiety disorder is effective, helping approximately 50% of GAD patientsachieve significant symptom reduction and high end-state functioning.

• CBT typically consists of psychoeducation, self-monitoring, relaxation, and cog-nitive restructuring.

• Additional techniques such as worry exposure, problem solving, and focusing onimproving positive aspects of one’s life are also potentially helpful.

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AUTHOR: Please provide reference for Barlow et al. 1996as cited in text.

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AUTHOR: Please provide reference for Borkovec and Abel1991 as cited in text.

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Recommended ReadingsHeimberg RG, Turk CL, Mennin DS: Generalized Anxiety

Disorder: Advances in Research and Practice. New York,Guilford, 2004


Hunot V, Churchill R, Teixeira V, et al: Psychological thera-pies for generalised anxiety disorder. Cochrane DatabaseSyst Rev 24:CD001848, 2007

Leahy RL: The Worry Cure: Seven Steps to Stop WorryStopping You. New York, Random House, 2005

Rygh JL, Sanderson WC: Treating Generalized Anxiety Dis-order: Evidence-Based Strategies, Tools, and Techniques.New York, Guilford, 2004

Zinbarg RE, Craske MG, Barlow DH: Mastery of Your Anx-iety and Worry (Therapist Guide), 2nd Edition. NewYork, Oxford University Press, 2006

Web SitesAnxiety Disorders Association of America: Generalized anx-

iety disorder (GAD). Available online at http://www.adaa.org/GettingHelp/AnxietyDisorders/GAD.asp. Accessed __________

Association for Advancement of Behavior Therapy: Anxiety.Available online at http://www.abct.org/docs/mental-health/factSheets/Anxiety.pdf. Accessed __________

National Institute of Mental Health: Generalized anxiety dis-o rd e r (GAD) . Ava i l ab l e on l ine a t h t tp : / /www.nimh.nih.gov/health/topics/generalized-anxiety-disorder-gad/index.shtml. Accessed __________

Anxiety Disorders Treatment Center: General anxiety: sum-mary. Available online at http://anxieties.com/gad.php.Accessed __________

AUTHOR: Please provide date of access for all Web sites.

TABLE 14–1 QUERIES

AUTHOR:

1) In row below Durham et al. 2004, left column: 6-monthfollow-up meant?

2) In row below Wells and King, left column: 12-month follow-up meant?

3) Crits-Christoph studies and Zinbarg study have no infoabout follow-up. Should row below reference in left col-umn read “No follow-up” as it does for some other stud-ies?

4) Has “N/A” been correctly defined as “not applicable”?(or should it be “not available”?)

5) Please provide definitions of 0, +, and – in last column,and clarify meaning of “0/–”.

6) Please provide a footnote “b” to correspond to theasterisk next to “61” in Crits-Christoph N column.

7) Please review all empty cells in follow-up column andconsider whether “N/A” should appear in them.

Thanks.


TABL

E 14

–1.

Resu

lts

of r

ecen

t ps

ycho

soci

al t

reat

men

t ou

tcom

e st

udie

s of

gen

eral

ized

anx

iety

dis

orde

r

Stud

y an

d fo

llow

-up

peri

odCo

ndit

ions

(tre

atm

ent

leng

th in

ses

sion

s)N

% Im

prov

emen

t in

an

xiet

y (I

E; S

Rs)

% D

rops

Follo

w-u

p

Dur

ham

et a

l. (1

994,

a 199

9, 2

003)

CB

T (8

or 2

0)38

IE: 5

5%; S

R:3

0%10

%+

1-ye

ar a

nd 8

–10-

year

follo

w-u

psP

SA (8

or 2

0)39

IE: 4

0%; S

R: 4

%24

%0/

–

BT

(8)

22IE

:44%

; SR

:15%

27%

0

Bow

man

et a

l. (1

997)

; Flo

yd e

t al.

(200

2)SE

T (C

BT

sel

f-he

lp)

19IE

: 33%

; SR

:20%

11%

0

2-ye

ar fo

llow

-up

Wai

tlist

19IE

: -3%

; SR

:4%

5%N

/A

Cri

ts-C

hris

toph

et a

l. (1

996,

200

4, 2

005)

SEP

(16)

61*s

ee q

uery

IE

: 44%

; SR

: 57%

10

ND

T (1

6)16

N/A

2

Lad

ouce

ur e

t al.

(200

0)C

BT

(16)

14IE

: 47%

; SR

: 42%

00

1-ye

ar fo

llow

-up

Wai

tlist

12IE

: 9%

; SR

: 4%

0

Ost

and

Bre

itzho

lz (2

000)

CT

(12)

18IE

: 47%

; SR

:21%

5%0

1-ye

ar fo

llow

-up

AR

(12)

15IE

: 47%

; SR

:20%

12%

0

Bon

d et

al.

(200

2)C

BT

(7)+

PB

O12

IE: 4

8%N

/AN

/A

No

follo

w-u

pN

DT

(7) +

PB

O14

IE: 4

4%N

/A

CB

T (7

) +

busp

iron

e11

IE: 5

6%N

/A

ND

T (7

) +

busp

iron

e7

IE: 5

1%N

/A

Arn

tz (2

003)

CT

(12)

25SR

: 18%

20%

0

6-m

onth

follo

w-u

pA

R (1

2)20

SR: 2

0%15

%0

Bor

kove

c et

al.

(200

2)C

T (1

4)25

IE: 6

6%; S

R:2

6%8%

0

2-ye

ar fo

llow

-up

AR

(14)

26IE

: 57%

; SR

:27%

15%

0

CB

T (1

4)25

IE: 6

4%; S

R:2

8%4%

0

Dug

as e

t al.

(200

3)C

BT

(14

grou

p 2

hour

s)25

IE: 4

7%; S

R:4

0%8%

0

2-ye

ar fo

llow

-up

Wai

tlist

27IE

: 9%

; SR

: 8%

7%

Dur

ham

et a

l. (2

004)

CB

T g

ood

prog

nosi

s (5

)29

IE: 4

1%; S

R 1

1%34

%0

6 m

onth

sC

BT

poo

r pro

gnos

is (1

0)27

IE: 3

5%; S

R 2

1%33

%0

CB

T p

oor p

rogn

osis

(20)

30IE

: 33%

; SR

13%

40%

0

Lin

den

et a

l. (2

005)

C

BT

(24

sess

ions

)36

IE: 3

5%; S

R: 1

5%14

%0


4 m

onth

s tr

eatm

ent,

8-m

onth

follo

w-u

pC

onta

ct c

ontr

ol (C

CG

)36

IE: 6

%; S

R: 3

%11

%N

/A

Fava

et a

l. (2

005)

CB

T (8

)10

IE: 3

2%; S

R: 4

8%20

%0

1-ye

ar fo

llow

-up

CB

T+

wel

l-be

ing

(4+

4)10

IE: 5

4%; S

R: 9

0%20

%0

Wel

ls a

nd K

ing

(200

6)C

T (2

–12)

10SR

: 61%

0%0

12 m

onth

s

Ferr

ero

et a

l. (2

007)

, P

SD (1

2 se

ssio

ns)

34 I

E: 2

9%3%

0

3 m

onth

s tr

eatm

ent,

9-m

onth

follo

w-u

pM

edic

atio

n33

IE: 4

3%15

%0

PSD

+m

edic

atio

n20

IE: 2

7%10

%0

Zin

barg

et a

l. (2

007)

CB

T (1

2)8

IE: 5

5%; S

R 3

9%12

%N

/A

Wai

tlist

10 I

E: 0

%; S

R: 4

%0%

Roe

mer

and

Ors

illo

(200

7)A

BT

(16

sess

ions

)19

IE: 5

4%; S

R: 4

9%16

%0/

–

3-m

onth

follo

w-u

p

Eva

ns e

t al.

(200

8)M

BC

T (8

, gro

up)

12SR

: 41%

8%N

/A

No

follo

w-u

p

Not

e.A

BT=

acce

ptan

ce b

ased

beh

avio

r th

erap

y, A

R=

appl

ied

rela

xatio

n, B

T=

beha

vior

the

rapy

, C

BT=

cogn

itive

beh

avio

ral

ther

apy,

CT=

cogn

itive

the

rapy

, IE

=in

depe

nden

t ev

alua

tor

ratin

gs,

MB

CT=

min

dful

ness

-bas

ed c

ogni

tive

ther

apy;

N/A

=not

app

licab

le; N

DT=

non-

dire

ctiv

e su

ppor

tive

ther

apy,

PB

O=

plac

ebo,

PSA

=ps

ycho

anal

ytic

ther

apy,

PSD

=A

dler

ian

psyc

hody

nam

ic p

sych

o-th

erap

y, S

EP=

supp

ortiv

e ex

pres

sive

psy

chod

ynam

ic th

erap

y, S

R=

self-

repo

rt r

atin

gs.

a In th

e D

urha

m e

t al.

(199

4) st

udy

ther

e w

ere

five

cond

ition

s, b

ut b

ecau

se o

f the

sim

ilari

ties i

n ou

tcom

es b

etw

een

long

(20

sess

ions

) and

shor

t (8

sess

ions

) tre

atm

ents

, the

se w

ere

com

bine

d in

the

tabl

e.*A

UT

HO

R: P

LE

ASE

PR

OV

IDE

A N

OT

E T

O C

OR

RE

SPO

ND

TO

AST

ER

ISK

AT

N-6

1 IN

CR

ITS-

CH

RIS

TO

PH

RO

W O

F M

AN

USC

RIP

T T

AB

LE

.

TABL

E 14

–1.

Resu

lts

of r

ecen

t ps

ycho

soci

al t

reat

men

t ou

tcom

e st

udie

s of

gen

eral

ized

anx

iety

dis

orde

r

Stud

y an

d fo

llow

-up

peri

odCo

ndit

ions

(tre

atm

ent

leng

th in

ses

sion

s)N

% Im

prov

emen

t in

an

xiet

y (I

E; S

Rs)

% D

rops

Follo

w-u

p

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Psychotherapy for Generalized Anxiety...

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