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Cognitive Behavioral Treatment of Generalized Anxiety Disorder


Title: Pollack APA Symposium Author: Visual International Keywords: Dr. Pollack/#1180 Description: STI-7165 3/16/98 Last modified by: Michael Otto – PowerPoint PPT presentation

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Title: Cognitive Behavioral Treatment of Generalized Anxiety Disorder

Cognitive Behavioral Treatment of Generalized
Anxiety Disorder
  • The original version of these slides was provided
  • Michael W. Otto, Ph.D.
  • with support from NIMH Excellence in Training
    Award at the Center for Anxiety and Related
  • at Boston University
  • (R25 MH08478)

Use of this Slide Set
  • Presentation information is listed in the notes
    section below the slide (in PowerPoint normal
    viewing mode).
  • A bibliography for this slide set is provided
    below in the note section for this slide.
  • References are also provided in note sections for
    select subsequent slides.

Slide Set Outline
  • Treatment outcome findings
  • Perspectives across meta analyses
  • Treatment models
  • Similarities (over differences)
  • Elements of treatment
  • What is accomplished in session
  • Future directions

Generalized Anxiety DisorderDiagnostic
  • Pervasive worry and chronic arousal
  • Residual category of panic disorder in DSM-III
  • Spheres of worry in DSM-III-R and chronic arousal
  • Excessive and uncontrollable worry and 3 of 6
    symptoms in DSM-IV
  • restless, keyed up, on edge
  • easily fatigued
  • difficulties concentrating
  • irritability
  • muscle tension
  • sleep disturbance

Core Patterns in GAD
  • Uncontrollable worry
  • Future orientation
  • Negative cognitive biases
  • Somatic arousal
  • Role and task inefficiency
  • Interpersonal aversiveness (unbalanced

GAD Core Treatment Elements
  • Information
  • Applied Relaxation
  • Cognitive Restructuring (probability estimates,
    coping estimates)
  • Cue-Controlled Worry (worry times problem
  • Worry Exposure (including existential topics)
  • Mindfulness

Meta-Analyses 5 Perspectives
  • All Randomized Trials (pre-post)
  • Norton Price, 2007
  • Placebo-Controlled Trials (controlled effect
  • Hofmann Smits, 2008
  • Elements of Treatment (controlled effect size)
  • Gould et al., 2004
  • Differential Efficacy (pre-post)
  • Siev Chambless, 2007
  • Gould et al., 2004
  • Effectiveness Trials (pre-post)
  • Stewart Chambless, 2009

Meta-Analysis of Randomized Anxiety Trials of CBT
(within ES) Norton Price, 2007, JNMD
Effect Size (d)
Hofmann Smits (2008) Meta-Analysis
  • Meta-analysis of well-controlled trials of CBT
    for anxiety
  • Inclusion criteria
  • Random assignment to either CBT or placebo
  • The psychological placebo had to involve
    interventions to control for nonspecific factors
    (e.g., regular contact with a therapist,
    reasonable rationale for the intervention,
    discussions of the psychological problem)

(No Transcript)
Meta-Analysis of Controlled Trials of CBT
(Between ES) Hofmann Smits, 2008, J
Clin Psychiatry
Effect Size (g)
Gould et al., 2004 Meta-Analysis
  • 16 studies
  • Mean drop-out rate 11.4
  • Mean 10.1 hours of treatment
  • No difference in outcome for studies allowing
    stabilized medications
  • Maintenance of treatment gains across 6 months

Meta-Analysis of CBT Gould et al., 2004Between
Effect Size (d)
Specificity of Treatment (Siev Chambless,
2007, JCCP)
  • Panic Disorder CT gt RT
  • Cognitive Therapy (CT) includes interoceptive
  • Relaxation Therapy (RT)

Meta-Analyses of Effectiveness Studies (Within
ES) (Stewart Chambless, 2009, JCCP)
Effect Size (d)
Comorbidity and Treatment(Newman et al., 2010)
  • 76 treatment seeking adults with GAD
  • 14 sessions of treatment
  • 60.5 had comorbidity
  • Comorbid diagnosis linked to greater GAD severity
    at pretreatment
  • Greater change with treatment for those with
    comorbid depression, social anxiety disorder,
    specific phobia
  • Normal maintenance of treatment gains
  • Benefits to social anxiety disorder and specific
    phobia were maintained over 2 years, whereas
    benefits to depression were not

CBT Models of GAD (Behar et al., 2009, J Anx
  • Avoidance Model of Worry and GAD
  • (Borkovec, 1994 Borkovec et al., 2004)
  • Intolerance of Uncertainty Model
  • (Dugas et al., 1995 Freeston et al., 1994)
  • Metacognitive Model
  • (Wells, 1995)
  • Emotion Dysregulation Model
  • (Mennin et al., 2002)
  • Acceptance-Based Model of Generalized Anxiety
  • (Roemer Orsillo, 2002, 2005)

Wells (1999)
  • Worry is a chain of catastrophising thoughts
    that are predominantly verbal. It consists of
    the contemplation of potentially dangerous
    situations and of personal coping strategies. It
    is intrusive and controllable although it is
    often experienced as uncontrollable. Worrying is
    associated with a motivation to prevent or avoid
    potential danger. Worry itself may be viewed as a
    coping strategy but can become the focus of

Two Types of Worry (Dugas Ladouceur, 2000)
  • Situations amenable to problem solving
  • Training in step-by-step problem solving
  • Situations that are not amenable to problem
    solving (hypothetical problems that never happen)
  • Worry times
  • Worry exposure

Avoidance Function of Worry
  • Worry, a verbal process, inhibits vivid mental
    imagery and associated anxiety (Borkovec)
  • Evidence that it does attenuate
  • somatic arousal at rest (Hoehn-Saric McLeod,
    1988 Hoehn-Saric, McLeod, Zimmerli, 1989
    Lyonfields, Borkovec, Thayer, 1995 Thayer,
    Friedman, Borkovec, 1996)
  • upon subsequent exposure to threat-related
    material (Borkovec Hu, 1990 Peasley-Miklus
    Vrana, 2000)

Worry and Conditioning
  • Non-clinical levels of worry are linked to
    greater conditionability
  • (Otto et al., 2008 Hermans et al., 2009)
  • Potential role for rumination in keeping
  • CS UCS link alive

  • Encourage a present focus vs. future (past)
  • Leave patients expectancy free

Positive Beliefs About Worries
  • Worrying
  • Is useful for finding solutions to problems
  • Is motivating helps get things done
  • Is protective from negative emotions
  • Can prevent negative outcomes
  • Is a positive personality trait
  • (Francis Dugas, 2004)

Negative Problem Orientation
  • Problems are threat to well-being
  • Doubt about problem-solving ability
  • Pessimism about problem solving outcome
  • Negative problem orientation is more specific to
    worry than depression in student samples, and is
    differentiated from neuroticism
  • (Robichaud Dugas, 2005, BRAT)

Intolerance of Uncertainty
  • Motivates unnecessary worry-based planning
  • What if X happens, could I cope by

All current models tend to underscore avoidance
of internal experiences
  • Cognitive avoidance
  • Emotional avoidance
  • Intolerance of uncertainty
  • Negative cognitive reactions to emotions
  • Combined With
  • Positive beliefs about worry
  • While being concerned about effects of worry

Treatment ElementsBorkovec
  • Awareness and self-monitoring
  • Relaxation
  • Cognitive therapy
  • Imagery rehearsal of coping strategies
  • (see Borkovec, 2006 for review)

Treatment ElementsWells
  • Case formulation
  • Socialization to treatment
  • Modifying negative beliefs about the
    uncontrollability of worry
  • Modifying beliefs about the danger of worry
  • Modifying positive beliefs about worry
  • (Wells, 1999)

Treatment ElementsDugas et al.
  • Uncertainty recognition and behavioral exposure
  • Re-evaluation of the usefulness of worry
  • Problem-solving training
  • Imaginal exposure
  • (Dugas et al., 2003)

Relaxation Strategies
  • Progressive Relaxation (PR e.g., Bernstein
    Borkovec, 1973)
  • Applied Relaxation (ARO st, 1987).
  • AR does include exposure elements

Mechanism of Relaxation Training (Ost, 1992)
  • Reduces general tension and anxiety (and link
  • Enhances awareness about how anxiety works,
    de-mystifying and diminishing its impact
  • Enhances self-efficacy individuals feel
    equipped to cope with anxiety

Relaxation Training
  • Feel the difference between tension and
  • Tense 7 seconds, relax 15
  • Specific muscle groups to learn the procedure
  • Group them as skill increases
  • Use 10-second relaxation cue

The Words of Worry
  • Non-specific and hard to dispute
  • It will be horrible
  • It will be a disaster
  • Downward Arrow Techniques to clarify worries and
    put them in a form appropriate for

Cognitive Restructuring
  • Self monitoring
  • Logical analysis
  • Probability overestimations
  • Overestimations of the degree of catastrophe
  • Ability to cope

Relapse Prevention in Depression - Metacognitive
  • Classic CT and mindfulness-based CT both enhance
    metacognitive awareness
  • Level of metacognitive awareness is linked to
  • Changing the relationship people have to their
    thoughts, rather than changing beliefs, may be
    important for preventing relapse
  • (Teasdale et al., 2002)

  • Curious attention to the present moment, in an
    open, nonjudgmental, and accepting manner
  • (Bishop et al., 2004 Germer, 2005 Kabat-Zinn,

Why Mindfulness?
  • Hayes and Feldman, 2004
  • Mindfulness training may enhance emotional
    regulation by addressing the patterns of
    over-engagement (e.g., rumination) and
    under-engagement (avoidance) that characterizes
    the disorder.
  • Target is a healthy level of engagement that
    allows clarity and functional use of emotional
  • Roemer et al, 2009
  • Non-clinical symptoms and clinical GAD status
    linked to lower mindfulness

Worry Time
  • Save up the worry (cue specificity)
  • End of the day worry time
  • In office (non-fun) setting
  • 45 min with writing
  • 10 min relaxation skills
  • Go have fun

GAD Worry Exposure
  • Metaphor Like watching a scary movie over and
    over decreased arousal and changed meaning of
    the worry
  • Apply exposure plus response prevention
    (including the use of tape loops)
  • The goal is elimination of the worry response via
    repeated exposure to core fears
  • This technique should also be coupled with the
    prescription to worry through one topic and not
    switch among spheres of worry

GAD Training in Normal Thinking
  • Teach normal thinking as alternative
    behavior. What does one think about when not
    preoccupied with worry?
  • Mindfulness of thinking states that are different
    from worry (e.g. daydreaming, experiencing,
    planning, enjoying)
  • Sensory awareness training
  • Staying in the moment
  • Use of worry times
  • Limited effects of exposure on valence/preference

Attention ModificationTraining - GAD
  • 29 treatment seeking patients
  • Random assignment (train away vs. no train threat
  • 8 sessions over 4 weeks
  • Goal
  • Change attentional bias
  • Change GAD symptoms
  • Succeeded with both
  • Between group effect size of .80
  • Least efficacy on worry
  • (Amir et al., 2009, J Abn Psych)

Attention Modification Training - GAD
  • Randomized clinical trial GAD (N 29)
  • Stimuli threatening or neutral words
  • 50 of those in the active attention modification
    program were classified as responders (no longer
    meeting DSM diagnosis for GAD) vs. 13 in the
    control condition

  • (Amir et al., 2009)

New Directions
  • Attentional training
  • Mindfulness/emotional tolerance training
  • Interoceptive exposure
  • Integrative treatment

GAD Interpersonal Roles
  • Polarizing the relationship the worry partner
  • Improving couples problem-solving

  • Nice convergence of strategies in the field
  • Need to convincingly beat relaxation training as
    a first step in care
  • Need to confirm resilience of treatment to
    depression (but emergent finding across anxiety
  • Room for improvement to achieve high end-state