Can the components of a cognitive model predict the severity of generalized anxiety disorder?

Over the past decade, a number of well-controlled studies have supported the validity of a cognitive model of generalized anxiety disorder (GAD) that has four main components: intolerance of uncertainty, positive beliefs about worry, negative problem orientation, and cognitive avoidance. Although these studies have shown that the model components are associated with high levels of worry in nonclinical samples and with a diagnosis of GAD in clinical samples, they have not addressed the question of whether the model components can predict the severity of GAD. Accordingly, the present study sought to determine if the model components are related to diagnostic severity, worry severity, and somatic symptom severity in a sample of 84 patients with a primary diagnosis of GAD. All model components were related to GAD severity, although positive beliefs about worry and cognitive avoidance were only modestly associated with the severity of the disorder. Intolerance of uncertainty and negative problem orientation had more robust relationships with the severity of GAD (and with worry severity, in particular). When participants were divided into Mild, Moderate, and Severe GAD groups, intolerance of uncertainty and negative problem orientation distinguished the Moderate and Severe GAD groups from the Mild GAD group, even when age, gender, and depressive symptoms were statistically controlled. Overall, the results lend further support to the validity of the model and suggest that intolerance of uncertainty and negative problem orientation are related to the severity of GAD, independently of sociodemographic and associated clinical factors. The theoretical and clinical implications of the findings are discussed.     

A Case of Premature Termination in a Treatment for Generalized Anxiety Disorder

In this paper we present a case of failure in an integrative treatment for generalized anxiety disorder (GAD) combining cognitive-behavioral therapy, an empirically supported treatment for GAD, and interpersonal-emotional processing therapy. The client of focus dropped out of treatment after the eighth session. Based on our analysis of this case, we discuss the participant, technical and relationship factors that were likely implicated in this case of premature termination in both of the cognitive-behavioral and interpersonal-emotional processing segments that comprised the treatment. Implications for practice, training and future research are also discussed.     

Clinical Experiences in Conducting Empirically Supported Treatments for Generalized Anxiety Disorder

Knowledge of the efficacy of cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD) predominantly derives from randomized controlled trials (RCTs). However, there may be unique or complex issues encountered in practice, but not necessarily in the context of a controlled clinical trial. Therefore, launching a systematic dialogue between researcher and practicing clinician can be instrumental in augmenting evidence-based therapies through identification of variables that promote and interfere with clinical effectiveness. Through an initiative sponsored by the American Psychological Association’s Divisions 12 (Society for Clinical Psychology) and 29 (Psychotherapy), this study aimed to examine clinical experiences conducting CBT for GAD. The participants were 260 psychotherapists who completed an online survey on assessment and therapeutic intervention utilization and their experience of factors that limit successful GAD treatment and symptom reduction. The majority of respondents reported 20 years or less experience using ESTs for GAD, typically treating clients in outpatient clinics, treatment centers, and private practice. Some of the most commonly used interventions address clients’ maladaptive cognitions and elevated anxiety and muscle tension typical of GAD. Approximately one half of respondents reported incorporating integrative techniques into treatment. Factors perceived as limiting effective GAD treatment included severity and chronicity of GAD, presence of comorbid conditions, stressful home and work environments, client motivation and resistance to treatment, and issues encountered when executing therapy techniques. This study provides researchers with clinically derived directions for future empirical investigation into enhancing efficacy of GAD treatment.     

Negative problem orientation (Part II): construct validity and specificity to worry

Negative problem orientation, a dysfunctional set of attitudes related to problem-solving ability, has been implicated as a process variable in several psychological disorders, notably depression and generalized anxiety disorder (GAD). The goal of the present study was two-fold: (1) to further examine the construct validity of a new measure of negative problem orientation, the negative problem orientation questionnaire (NPOQ), through its relationship to conceptually similar variables, and (2) to investigate the specificity of negative problem orientation to worry, the cardinal feature of GAD, compared to depression. The sample consisted of 148 university students who completed six questionnaires, the NPOQ and measures of worry, depression, pessimism, self-mastery, and neuroticism. Multiple hierarchical regressions revealed that when entered in the last step following demographic information and personality variables (pessimism, self-mastery, and neuroticism), the NPOQ accounted for 5.6% of the variance in worry scores compared to 1.6% of the variance in depression scores. It was concluded that the NPOQ shows evidence of construct validity, and that the process variable of negative problem orientation appears to have greater specificity to worry than depression. Implications for the understanding of worry and GAD are discussed.     

The structure of distress following trauma: posttraumatic stress disorder, major depressive disorder, and generalized anxiety disorder

The current report used confirmatory factor analysis to examine the latent structures of both key features and associated symptoms of three disorders that commonly develop following a traumatic event: posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD). Participants were 228 motor-vehicle accident survivors who sought treatment for emotional difficulties. PTSD, MDD, and GAD were assessed with a combination of self-report and interview-based measures. The results of construct level analyses suggested that PTSD, MDD, and GAD are distinguishable but highly correlated disorders following a traumatic event. Symptom level analyses supported a model where the Reexperiencing, Avoidance, and Hypervigilance factors were subsumed under the PTSD construct. However, in this model the Dysphoria factor was a higher order construct correlated with the PTSD, MDD, and GAD factors, suggesting that the Dysphoria cluster may not be unique to PTSD. Diagnostic and theoretical implications of these results are discussed.     

The Contribution of Worry Behaviors to the Diagnosis of Generalized Anxiety Disorder

Worry behaviors (i.e., overt acts to avoid or cope with worry-induced distress) have been recognized as being important in the psychopathology and treatment of generalized anxiety disorder (GAD). This study evaluated the worry behaviors criterion proposed for DSM-5 GAD, but was ultimately not adopted due to insufficient evidence. In 800 outpatients with emotional disorders (366 with GAD), most patients with GAD (92.6%) met the proposed worry behaviors criterion, which was at a rate significantly higher than other patient groups (e.g., patients with mood disorders). Patients who met the worry behaviors criterion had more severe GAD than patients who did not. The worry behaviors criterion, and 3 of its 4 constituent behaviors, were associated with no better than “fair” interrater reliability. Diagnostic reliability of GAD was not improved in cases where both interviewers agreed the worry behaviors criterion was met. The worry behaviors criterion significantly predicted DSM-5 GAD holding core GAD features constant (e.g., excessive worry), but this contribution was weak and did not appreciably improve the classification accuracy of GAD diagnostic status. Mixed support was obtained for the discriminant validity of the worry behaviors criterion in relation to mood disorders. Raising the proposed threshold of the criterion (requiring 2 instead of 1 behaviors) did not result in a substantial improvement in reliability, prediction, and classification accuracy. Although additional research is warranted (e.g., importance of worry behaviors in the treatment and natural course of GAD), the results raise questions about the role of worry behaviors in the diagnostic classification of GAD.     

Efficacy of a cognitive-behavioural therapy administered by videoconference for generalized anxiety disorder

IntroductionDelivering psychotherapy by videoconference could considerably extend the accessibility of empirically validated treatments.ObjectiveThe aim of this study was to evaluate the efficacy of a cognitive-behavioural therapy (CBT) for generalized anxiety disorder (GAD), administered via videoconference.MethodFive participants with a primary diagnosis of GAD took part in an experimental multiple baseline case study protocol. The efficacy of the treatment was evaluated using a semi-structured interview, self-report questionnaires, and daily self-monitoring diaries.ResultsThe results demonstrate that overall, participants’ conditions were improved following treatment and they no longer met the diagnostic criteria for GAD in the short-term. Participants’ conditions improved clinically and statistically at each follow-up point, achieving a greater global level of functioning at post-test, as well as at 3-month and 12-month follow-up.ConclusionClinical implications of this new treatment modality and directions for future research are discussed.     

Chronic sodium azide treatment impairs learning of the Morris water maze task.

A reduction in the activity of cytochrome oxidase, a respiratory chain enzyme, has been recently identified in mitochondria from blood platelets and postmortem brain tissue from Alzheimer's disease (AD) patients. We have developed an animal model of this deficit in rats by chronic subcutaneous infusion of sodium azide, a selective inhibitor of cytochrome oxidase, delivered via Alzet 2ML4 osmotic minipumps. In previous work, azide-treated rats were impaired in an appetitively motivated spatial learning task, the radial arm maze. In the present investigation, we tested male Sprague-Dawley rats (350-400 g), which were tonically infused with azide or saline, on an aversively motivated spatial task, the Morris water maze. Azide-treated rats were impaired on both acquisition and retention of this task, without showing evidence of a motor impairment. Thus, the present results are consistent with previous findings showing that chronic azide treatment produces a learning and memory deficit. These findings strengthen the hypothesis that azide treatment in rats produces a useful animal model of some aspects of AD.     

Behavioral Experiments for Intolerance of Uncertainty: A Randomized Clinical Trial for Adults With Generalized Anxiety Disorder

Sophisticated multicomponent treatments for adults with generalized anxiety disorder (GAD) have been developed over the past three decades. Although these comprehensive treatments have produced encouraging results, they appear to be less efficacious than treatments for other anxiety disorders. The goal of this randomized controlled trial is to test a newly developed, highly focused treatment for adults with GAD: Behavioral Experiments for Intolerance of Uncertainty. Sixty (60) participants (51 women, 9 men), with a mean age of 34.60 years (range: 19 to 67 years), were randomized to either treatment (n = 30) or wait-list control (n = 30). Treatment consisted of 12 weekly 1-hour sessions in which participants learned to use behavioral experiments to test their catastrophic beliefs about uncertainty. Assessments were conducted at pre-, mid- and postcondition, and at 6- and 12-month follow-up. The primary outcome was the severity of GAD, and secondary outcomes were worry, depression, somatic anxiety, and intolerance of uncertainty. Using growth curve modeling, we found that (1) the treatment group was superior to the wait-list group in terms of change from pre- to posttest on all outcomes; (2) the combined sample (once wait-listed participants received treatment) evidenced large and significant decreases on all outcomes; and (3) treatment gains were either maintained or increased over the 12-month follow-up period of the study. The new treatment is a promising treatment option for adults with GAD considering that it may be as efficacious as more comprehensive evidence-based psychological treatments for GAD.     

Worry: daily self-report in clinical and non-clinical populations

The present study establishes an ecologically-valid point of reference for generalized anxiety disorder (GAD) treatment outcome studies. Although worry is the main diagnostic criterion for GAD, it is also a common and everyday cognition. Few studies have investigated the normal manifestation of worry in a non-clinical population. For this research, time spent worrying and the tendency to worry were measured in a non-clinical sample (n = 36), where GAD was screened-out, and results were compared to those obtained from a GAD sample (n = 60). Participants recorded the time spent worrying in self-monitoring notebooks for two consecutive weeks and completed the French version of the Penn State Worry Questionnaire (PSWQ). It was found that the non-GAD group reported less time spent worrying on a daily basis as well as a lower tendency to worry than the GAD group. Results are discussed in terms of treatment implications.     

Working memory capacity and spontaneous emotion regulation in generalised anxiety disorder

Researchers have postulated that deficits in cognitive control are associated with, and thus may underlie, the perseverative thinking that characterises generalised anxiety disorder (GAD). We examined associations between cognitive control and levels of spontaneous state rumination following a stressor in a sample of healthy control participants (CTL; n?=?27) and participants with GAD (n?=?21). We assessed cognitive control by measuring working memory capacity (WMC), defined as the ability to maintain task-relevant information by ignoring task-irrelevant information. To this end, we used an affective version of the reading span task with valenced (negative or neutral) distractors. Lower WMC in the presence of negative distractors was associated with greater state rumination in the GAD group, but not in the CTL group. These findings suggest that difficulty maintaining task-relevant information due to interference from negative distractors contributes to perseverative thinking in GAD.     

Generalized anxiety disorder: acute and chronic treatment

Clinical and epidemiological data suggest that generalized anxiety disorder (GAD) is a chronic illness causing patients to suffer for many years leading to significant distress in daily life functioning. The literature suggests the several conclusions. GAD is a disorder in need of appropriate treatment and often has a chronic course with comorbid conditions, such as major depression and other anxiety disorders. Benzodiazepines, while effective anxiolytic agents acutely, when prescribed for >4 weeks cause rebound anxiety and following prolonged therapy may lead to withdrawal symptoms. Antidepressants cause significant anxiety relief compared with placebo and for psychosocial treatment cognitive-behavioral therapy is an efficacious psychosocial treatment. Many GAD patients are in need of long-term medication management. Furthermore, there is limited data for patients diagnosed with GAD the treatment outcome with the combination of medication and psychotherapy both acutely and long-term; how to best sequence these treatments; for those patients who do not meet remission criteria what is the ideal approach for augmentation; and for patients with treatment-refractory GAD the empirical evidence is lacking on medication switching and augmentation strategies. Research is needed in the area of developing treatment strategies for patients suffering from treatment-refractory GAD. There is still an urgent need to explore treatment combinations and duration strategies in the management of patients suffering with GAD.     

Preliminary tests of a cognitive model of generalized anxiety disorder.

Although worry is the central feature of Generalised Anxiety Disorder (GAD), little is known about the factors that contribute to pathological or problematic worry. In a recent cognitive model of GAD, Wells, A. (1995) proposed that negative appraisal of worrying itself (meta-worry or type 2 worry) should be distinguished from other types of worrying (type 1 worry). A central feature of this model is the idea that individuals with GAD hold rigid positive beliefs about the usefulness of worrying as a coping strategy. However, these individuals also hold negative beliefs and appraise worrying as uncontrollable and dangerous. This combination of cognitions and associated responses leads to an increased frequency and generality of worrying, and thus to the pathological worry characteristic of GAD. This paper reports a preliminary test of the hypothesis that meta-worry contributes to problematic and pathological worrying, and this relationship is independent of the frequency of other types of worry. In testing for associations between worry dimensions we controlled for overlaps with Trait anxiety, and the controllability of worrying. Results of a series of regression analyses support the hypothesis that pathological worry is associated with meta-worry and this association is independent of Trait-anxiety and type 1 worry. The clinical implications of these data are briefly discussed.     

Interpersonal pathoplasticity in individuals with generalized anxiety disorder

Recent theories of generalized anxiety disorder (GAD) have emphasized interpersonal and personality functioning as important aspects of the disorder. We examined heterogeneity in interpersonal problems in 2 studies of individuals with GAD (n = 47 and n = 83). Interpersonal subtypes were assessed with the Inventory of Interpersonal Problems-Circumplex (Alden, Wiggins, & Pincus, 1990). Across both studies, individuals with GAD exhibited heterogeneous interpersonal problems, and cluster analyses of these patients' interpersonal characteristics yielded 4 replicable clusters, identified as intrusive, exploitable, cold, and nonassertive subtypes. Consistent with our pathoplasticity hypotheses, clusters did not differ with GAD severity, anxiety severity, or depression severity. Clusters in Study 2 differed on rates of personality disorders, including avoidant personality disorder, further providing support for the validity of interpersonal subtypes. The presence of interpersonal subtypes in GAD may have important implications for treatment planning and efficacy.     

Évaluation de l’efficacité d’un traitement cognitif-comportemental pour le trouble d’anxiété généralisée combiné à des stratégies de régulation des émotions et d’acceptation et d’engagement expérientiel

The objective of this article is to examine the efficacy of a new cognitive-behavioral treatment, which combines emotion regulation strategies, and acceptance and commitment-based strategies to cognitive-behavioral supported treatment for generalized anxiety disorder (GAD). A single-case multiple baseline design was used to measure the effect of a 19-week treatment on three participants. Semi-structured interviews, self-report questionnaires, and daily self-monitoring were used to assess symptoms of GAD, general anxiety, depression, and quality of life. These instruments were administered at different times. At post-treatment, two out of the three participants showed a clinically significant improvement and no longer met GAD criteria. These results were maintained at the three-month follow-up. For the third participant, a considerable improvement was observed at the end of treatment but only reached clinical significance at the follow-up. The results of this study suggest that this type of treatment was effective in reducing anxiety and depression symptoms and in improving quality of life of GAD patients. Controlled studies involving bigger sample sizes are needed to determine the efficacy of this new treatment. Future research should also examine the separate and specific contribution of each therapy component in treatment efficacy.     

Emotion Regulation Therapy: An Integrative Approach to Treatment-Resistant Anxiety Disorders

Cognitive-behavioral, psychodynamic, and experiential approaches have historically been characterized by differing definitions of emotions and beliefs concerning their role in psychopathological process and treatment. However, given recent advances in the basic psychological sciences of emotion and emotion regulation, theoretical orientations are converging on similar viewpoints as to the functional role of emotions in conceptualizing and treating of a variety of disorders. One such area where emotions and their regulation may play a significant role is in chronic, complex, and treatment-resistant forms of anxiety disorders such as generalized anxiety disorder (GAD). A review of the historical approaches to emotions in the major theoretical orientations is presented. Following this, a model of emotion disruption and dysregulation is presented as it relates to anxiety disorders and GAD, in particular. Finally, a new treatment for GAD, emotion regulation therapy, aimed at ameliorating dysfunctional affective processes, is described.     

Interpersonal Problems,Mindfulness, and Therapy Outcome in an Acceptance-Based Behavior Therapy for Generalized Anxiety Disorder

Objective: To better understand the role interpersonal problems play in response to two treatments for generalized anxiety disorder (GAD); an acceptance-based behavior therapy (ABBT) and applied relaxation (AR), and to examine how the development of mindfulness may be related to change in interpersonal problems over treatment and at follow-up. Method: Eighty-one individuals diagnosed with GAD (65.4% female, 80.2% identified as white, average age 32.92) were randomized to receive 16 sessions of either ABBT or AR. GAD severity, interpersonal problems, and mindfulness were measured at pre-treatment, post-treatment, 6-month follow-up, and 12-month follow-up. Results: Mixed effect regression models did not reveal any significant effects of pre-treatment interpersonal problems on GAD severity over treatment. After controlling for post-treatment GAD severity, remaining post-treatment interpersonal problems predicted 6- but not 12-month GAD severity. Participants in both conditions experienced a large decrease in interpersonal problems over treatment. Increases in mindfulness over treatment and through follow-up were associated with decreases in interpersonal problems, even when accounting for reductions in overall GAD severity. Conclusions: Interpersonal problems may be an important target of treatment in GAD, even if pre-treatment interpersonal problems are not predictive of outcome. Developing mindfulness in individuals with GAD may help ameliorate interpersonal difficulties among this population.     

An examination of hypervigilance for external threat in individuals with generalized anxiety disorder and individuals with persecutory delusions using visual scan paths

One account of generalized anxiety disorder (GAD) is that it results from hypervigilance, manifest as excessive scanning of the external environment and preferential attention to threat. However, for individuals with GAD, there has been no direct study of scanning, and evidence for preferential attention to threat has only been found for threat-words. We therefore devised a new measure of hypervigilance. Visual scan paths were recorded of individuals with GAD (N=12) and people without a psychiatric illness (N=12) viewing complex pictures that varied in threat content. People with persecutory beliefs (N=11) also participated in the study to test the hypothesis that anxiety, via such hypervigilant cognitive processes, may contribute to the maintenance of delusions. Compared with the control group, the anxious individuals were not found either to scan excessively for or to look at threat. The anxiety group was therefore not hypervigilant for external threat, which is inconsistent with the hypervigilance model. As a consequence, the hypothesis that anxiety maintains delusions was not tested. However, additional support was found for the hypothesis that people with delusions form rapid judgements on the basis of less data-gathering than control groups who are either anxious or have no psychiatric illness.     

Interpersonal subtypes within generalized anxiety disorder

In this study, we addressed the heterogeneity in interpersonal problems across patients with generalized anxiety disorder (GAD). We assessed interpersonal problems by the Inventory of Interpersonal Problems (IIP-C; Horowitz, Alden, Wiggins, & Pincus, 2000) in a sample of 78 GAD patients. We used IIP-C profiles describing interpersonal characteristics of the total GAD sample as well as clustered GAD interpersonal subtypes. Although the overall sample was located in the friendly submissive quadrant of the circumplex model, this was true only for the Exploitable cluster, which includes more than 50% of the patients. Importantly, clusters of GAD patients with other locations reporting predominantly Cold, Nonassertive, or Intrusive interpersonal problems were also identified. The 4 clusters did not differ in terms of gender, comorbid disorders, or the severity of depression or anxiety. Thus, the assessment of interpersonal problems provides additional diagnostic information covering the heterogeneity of GAD patients. This information could be used for differential indication and individual case formulation in GAD.     

Combining computerized home-based treatments for generalized anxiety disorder: an attention modification program and cognitive behavioral therapy

Generalized anxiety disorder (GAD) is a common and disabling condition associated with significant personal and societal costs. Although efficacious treatments exist for GAD, the majority of these individuals fail to access our most effective treatments. In the current paper, we report the results of an open trial that examined the efficacy of a computer-delivered home-based treatment program for GAD. Twenty-one individuals seeking treatment for GAD received a self-administered program over 6 weeks that comprised two components: (1) an Attention Modification Program (AMP) designed to facilitate attentional disengagement from threat-relevant stimuli and (2) brief computer-delivered cognitive and behavioral treatment modules (CCBT). Fourteen of the 21 enrolled participants (67%) completed the treatment program. Intent-to-treat and completer analyses revealed that AMP+CCBT resulted in significant reductions in clinician- and self-rated symptoms of anxiety, worry, depression, and functional impairment. Moreover, treatment completers displayed significant reductions in attentional bias for threat from pre- to postassessment. Change in attentional bias for threat from pre- to postassessment was associated with change in worry symptoms. Finally, 79% of participants no longer met DSM-IV criteria for GAD at postassessment and 36% were classified as remitted (Hamilton Rating Scale for Anxiety ≤7; Rickels et al., 2006). These results suggest that computer-delivered AMP+CCBT may serve as an effective and easily accessible treatment option for individuals with GAD.