The effects of modifying interpretation bias on worry in generalized anxiety disorder

This study investigated whether facilitating a benign interpretive bias decreases negative thought intrusions in generalized anxiety disorder (GAD). Clients were randomly allocated to an interpretation modification condition in which they repeatedly accessed benign meanings of emotionally ambiguous homographs and scenarios, or to a control condition in which they accessed threat and benign meanings with equal frequency. Worry frequency was assessed using a breathing focus task that involved categorising the valence of thought intrusions before and after an instructed worry period. Interpretation bias was assessed during the modification tasks, and on a different measure of interpretation bias (sentence completion) following a period of worry. The experimental procedure modified interpretations made during training, and in the later sentence completion task. Furthermore, compared to the control group, the benign group showed fewer negative thought intrusions during breathing focus (as rated by both participants and an assessor). These findings show that it is possible to induce a more benign interpretive bias in GAD clients and that this reduces negative thought intrusions.     

Therapeutic alliance in guided internet-delivered cognitive behavioural treatment of depression, generalized anxiety disorder and social anxiety disorder

Guided internet-delivered cognitive behaviour therapy (ICBT) has been found to be effective in several controlled trials, but the mechanisms of change are largely unknown. Therapeutic alliance is a factor that has been studied in many psychotherapy trials, but the role of therapeutic alliance in ICBT is less well known. The present study investigated early alliance ratings in three separate samples. Participants from one sample of depressed individuals (N = 49), one sample of individuals with generalized anxiety disorder (N = 35), and one sample with social anxiety disorder (N = 90) completed the Working Alliance Inventory (WAI) modified for ICBT early in the treatment (weeks 3-4) when they took part in guided ICBT for their conditions. Results showed that alliance ratings were high in all three samples and that the WAI including the subscales of Task, Goal and Bond had high internal consistencies. Overall, correlations between the WAI and residualized change scores on the primary outcome measures were small and not statistically significant. We conclude that even if alliance ratings are in line with face-to-face studies, therapeutic alliance as measured by the WAI is probably less important in ICBT than in regular face-to-face psychotherapy.     

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.     

Applied relaxation vs. cognitive therapy in the treatment of generalized anxiety disorder

The present study investigated the efficacy of a coping-technique, applied relaxation (AR) and cognitive therapy (CT), in the treatment of generalized anxiety disorder. Thirty-six outpatients fulfilling the DSM-III-R criteria for generalized anxiety were assessed with independent assessor ratings and self-report scales before and after treatment and at a 1 yr follow-up. The patients were randomized and treated individually for 12 weekly sessions. The results showed that both treatments yielded large improvements, which were maintained, or furthered at follow-up. There was no difference between AR and CT on any measure. The drop-out rate was 12% for AR and 5% for CT. The proportions of clinically significantly improved patients were 53 and 62% at post-treatment and 67 and 56% at follow-up for AR and CT, respectively. Besides affecting generalized anxiety the treatments also yielded marked and lasting changes on ratings of worry, cognitive and somatic anxiety and depression. The conclusion that can be drawn is that both AR and CT have potential as treatments for generalized anxiety disorder but they have to be developed further in order to increase the efficacy to the level usually seen in panic disorder, 80-85% clinically improved.     

A preliminary investigation of impulsivity in generalized anxiety disorder

Few studies have examined the association between impulsivity and generalized anxiety disorder (GAD). This study examined whether individuals with probable GAD display impulsivity in a particular way, and the extent to which impulsivity uniquely predicts GAD severity and GAD status, over and above intolerance of uncertainty (IU), a key cognitive factor in GAD. Individuals with (n = 63) and without (n = 77) probable GAD completed self-report measures of impulsivity and IU. Results revealed that elevations in the severity of GAD symptoms and in IU were associated with impulsive actions in the face of negative affect (i.e., negative urgency), but also greater premeditation and lower “functional” impulsivity (i.e., the ability to take quick action when it is advantageous to do so). Impulsivity led to an increment in the prediction of GAD symptoms and GAD status, over and above IU. Negative urgency and lower functional impulsivity were significant unique predictors of GAD severity or GAD status. The findings highlight a need to consider impulsivity in theories that implicate intolerance of negative affect and uncertainty in excessive and uncontrollable worry.     

Memory bias for threat in generalized anxiety disorder: the potential importance of stimulus relevance

Information processing models propose that anxious individuals are characterized by memory biases for mood-congruent threat information. However, evidence for memory biases in generalized anxiety disorder (GAD) has been mixed at best. Given the heterogeneity of concerns in GAD, previous use of nomothetic stimulus sets may have precluded detection of memory biases. Therefore, in order to guarantee the relevance of the stimuli used, in the current study individuals with GAD each individually selected words that were of personal relevance to them. Using these idiographically selected words with 23 individuals with DSM-IV GAD and 23 non-anxious controls (NACs), results showed an implicit memory bias for threat words in individuals with GAD compared with NACs. Furthermore, there was additional evidence that individuals with GAD may also be characterized by explicit memory bias for threat words. The magnitude of group differences for explicit recall of threat words was similar to those previously observed in panic disorder. Limitations and future directions are discussed.     

Regulation of hypothalamic-pituitary-adrenal activity in response to cognitive therapy in patients with generalized anxiety disorder

The aim of this study was to evaluate the efficacy of cognitive therapy (CT) in the treatment of generalized anxiety disorder (GAD), as it would be reflected through both psychological and psychoneuroendocrinological parameters. For this purpose, a group of outpatients with GAD were treated with CT for up to a maximum of 24 sessions. In order to assess psychological and biological changes, anxiety-related symptoms were evaluated according to the Hamilton Anxiety Rating Scale (HAM-A), and the hypothalamic-pituitary-adrenal (HPA) function was determined through assessment of circulating cortisol levels. A significant decrease in the HAM-A scores, along with significant changes in plasma cortisol levels, were observed after completion of treatment with CT. These observations contribute to demonstrate that the effect of certain psychotherapeutic approaches, such as CT, may be observed at both psychological and biological levels.     

A comparison of cognitive-behavior therapy with interpersonal and cognitive behavior therapy in the treatment of generalized anxiety disorder

Objective: The aim of this study was to compare the effectiveness of cognitive behavior therapy with the combination of cognitive behavior therapy and interpersonal therapy on decreasing the excessiveness of pathological worry and increasing happiness of the individuals with generalized anxiety disorder.

Method: The sample consisted of 36 female undergraduate students who referred themselves to the Isfahan University Counseling Center and met the criteria for GAD. They were randomly assigned into three groups; namely, two experimental groups and one control group. Before receiving the interventions all of the groups completed Penn State Worry Questionnaire and Oxford Happiness Inventory. One of the experimental groups underwent cognitive behavior therapy and the other one received the integration of cognitive behavior therapy and interpersonal therapy. The control group received no intervention.

Result: The statistical analyses indicated that the differences between the CBT and CBT+ IPT groups on excessive worry and happiness in the post tests were not significant. But significant mean differences were observed in the follow-ups regarding pathological worry and happiness between two groups.

Conclusion: It can be concluded that the integration of cognitive behavior therapy and interpersonal therapy can be applied as an effective intervention for decreasing the rate of GADs’ relapses after cognitive behavior therapy.     

The effectiveness of cognitive behavioral therapy for generalized anxiety disorder in a frontline service setting

The goal of the current study was to test the generalizability of cognitive behavioral therapy (CBT) for generalized anxiety disorder (GAD) in a frontline service setting. Twenty-nine patients who presented to treatment clinics with problematic worry were provided CBT for GAD. Among the intent-to-treat sample, there were no significant changes in worry or depression from pre- to posttreatment. Treatment completers showed significant pre- to posttreatment reductions on measures of worry and depression. The magnitude of change was smaller than has been reported in randomized control trials (RCTs). Although the frontline service setting differed from RCT settings in multiple ways, treatment completers nonetheless achieved moderate to large decreases in self-reported worry and depression.     

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.     

The role of anger in generalized anxiety disorder

Little is known about the role of anger in the context of anxiety disorders, particularly with generalized anxiety disorder (GAD). The aim of study was to examine the relationship between specific dimensions of anger and GAD. Participants (N?=?381) completed a series of questionnaires, including the Generalized Anxiety Disorder Questionnaire (GAD-Q-IV; Newman et al., 2002, Behavior Therapy, 33, 215-233), the State-Trait Anger Expression Inventory (STAXI-2; Spielberger 1999, State-Trait Anger Expression Inventory-2: STAXI-2 professional manual, Odessa, FL: Psychological Assessment Resources) and the Aggression Questionnaire (AQ; Buss & Perry 1992, Journal of Personality and Social Psychology, 63, 452-459). The GAD-Q-IV identifies individuals who meet diagnostic criteria for GAD (i.e. GAD analogues) and those who do not (non-GAD). The STAXI-2 includes subscales for trait anger, externalized anger expression, internalized anger expression, externalized anger control and internalized anger control. The AQ includes subscales for physical aggression, verbal aggression, anger and hostility. The GAD-Q-IV significantly correlated with all STAXI-2 and AQ subscales (r's ranging from .10 to .46). Multivariate analyses of variance revealed that GAD analogues significantly differed from non-GAD participants on the combined STAXI-2 subscales (η(2)?=?.098); high levels of trait anger and internalized anger expression contributed the most to GAD group membership. GAD analogue participants also significantly differed from non-GAD participants on the combined AQ subscales (η(2)?=?.156); high levels of anger (affective component of aggression) and hostility contributed the most to GAD group membership. Within the GAD analogue group, the STAXI-2 and AQ subscales significantly predicted GAD symptom severity (R (2)?=?.124 and .198, respectively). Elevated levels of multiple dimensions of anger characterize individuals who meet diagnostic criteria for GAD.     

Cognitions in generalized anxiety disorder and panic disorder patients. A prospective approach.

Self-observations of cognitions during episodes of anxiety were examined in 38 patients with generalized anxiety disorder and 36 patients with panic disorder. Two independent observers who where blind to the diagnoses categorised the cognitions. The inter-rater reliability was high (mean kappa 0.82). The GAD-patients had significantly more cognitions in the following categories: interpersonal confrontation, competence, acceptance, concern about others and worry over minor matters, while the PD-patients had significantly more cognitions in the physical catastrophe category. Furthermore, GAD-patients with a comorbidity of social phobia reported more cognitions regarding social embarrassment than did GAD-patients with other or no (axis-I) comorbidity. The results of this study support the cognitive theory regarding the cognitive specificity of anxiety disorders. The implications of these results are discussed, along with the issues of reliability and validity of the instrument used.     

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.     

Differentiating anxiety and depression in older adults with generalized anxiety disorder

To examine affect and cognition in differentiating anxiety and depression, 83 older participants with generalized anxiety disorder completed the Cognitive Checklist (CCL) and the Positive and Negative Affect Schedule (PANAS). A 3-factor solution was found for the PANAS: positive affect (PA), anxiety and anger (Negative Affect 1 [NA-1]), and guilt and shame (Negative Affect 2 [NA-2]). A 2-factor structure was noted for the CCL. Correlations with anxiety and depression measures suggested that the CCL Depression (CCL-D) subscale showed stronger correlations with depression, whereas the CCL Anxiety subscale did not uniquely correlate with anxiety. The NA-1 subscale correlated positively with measures of depression and anxiety, whereas the PA subscale showed negative correlations. Hierarchical regression suggested that the CCL-D subscale was a significant predictor of self-reported depression.     

Interpretive cues and ambiguity in generalized anxiety disorder

The current study investigated whether generalized anxiety disorder (GAD) individuals rely on antecedent information to interpret ambiguity and whether reliance on such preceding cues persists in the absence of potential threat. Twenty-six GAD and 23 nonanxious control college students performed a lexical decision task, using homographs (i.e. words with multiple meanings) as ambiguous primes. In half the trials, a homograph prime that possessed both threat-related, as well as neutral meanings was followed by a target word related to one of these two meanings. In addition, each ambiguous prime was immediately preceded by a series of four antecedent words that were either: (a) associated with the threatening meaning of the prime; (b) associated with the neutral meaning of the prime; or (c) unrelated to either meaning of the homograph, as well as the target. Homographs for which both meanings were neutral in valence comprised the other half of the trials. Effect size statistics suggest that GAD participants utilized the antecedent words to interpret the homograph primes with threat-related meanings, unlike their nonanxious counterparts (p<0.06). When both meanings of the homograph prime were neutral in valence, the GAD group appeared deficient in the use of preceding information to interpret the ambiguous prime.