Changes in Decentering and Reappraisal Temporally Precede Symptom Reduction During Emotion Regulation Therapy for Generalized Anxiety Disorder With and Without Co-Occurring Depression

Emotion Regulation Therapy (ERT) has demonstrated efficacy in both open and randomized trials for generalized anxiety disorder (GAD) with and without co-occurring depression. An important goal in ERT is to teach clients adaptive emotion regulation, including healthier metacognitive abilities such as decentering and cognitive reappraisal. A few studies thus far have demonstrated a mediating role for these metacognitive abilities in other cognitive behavioral therapies (CBTs) for GAD. However, a drawback to most of these has been the ability to demonstrate a causal role for improved metacognitive abilities in outcome. In the present study, we utilized multilevel time-lagged segment analyses to explore the temporal dynamics between session-by-session changes in metacognition and anxiety outcomes from ERT. Thirty-one young adults diagnosed with GAD with and without co-occurring depression received 16 sessions of ERT. Prior to each session, participants completed questionnaires pertaining to metacognition (i.e., decentering and cognitive reappraisal) and anxiety symptoms (i.e., worry, trait anxiousness, and generalized anxiety). Changes in decentering temporally preceded changes in worry and trait anxiousness of a medium to large magnitude, and changes in cognitive reappraisal temporally preceded changes in all three outcomes of a medium to large magnitude. The reverse direction, where mediators were predicted by outcomes, was nonsignificant. These findings support the notion that adaptive metacognitive emotion regulation is involved in reducing worry and anxiety in GAD. Having a clearer understanding of the temporal dynamics between metacognitive abilities and symptoms of anxiety can inform and improve not only ERT but other CBTs for GAD, as well.     

'Minor GAD': characteristics of subsyndromal GAD in older adults

Subsyndromal emotional symptoms are common in older adults and are associated with increased disability, health care utilization, and risk for developing psychiatric disorders. The purpose of this study was to examine subsyndromal generalized anxiety disorder (GAD) in older adults. Participants included 30 older adults with diagnosable GAD, 19 with subsyndromal anxiety symptoms [minor GAD; (MGAD)], and 21 normal control volunteers (NC). Participants were assessed using the Anxiety Disorders Interview Schedule for DSM-IV and completed self-report measures of anxiety, worry, depression, and life satisfaction. Excessive worry on more days than not, difficulty controlling worry, and clinically significant distress or impairment were the diagnostic criteria endorsed by MGAD participants least often. Therefore, these criteria may be useful in distinguishing between GAD and subsyndromal GAD. Self-reported anxiety and worry also systematically differed across groups in the expected directions, with a discriminant analysis yielding good classification of the GAD and NC groups based on these measures. Categorization of MGAD participants generally was poor, with most misclassified as GAD patients. Clinical implications of these findings are discussed.     

What’s in a name? Intolerance of uncertainty,other uncertainty-relevant constructs,and their differential relations to worry and generalized anxiety disorder*

A number of studies have examined the association of intolerance of uncertainty (IU) to trait worry and generalized anxiety disorder (GAD). However, few studies have examined the extent of overlap between IU and other psychological constructs that bear conceptual resemblance to IU, despite the fact that IU-type constructs have been discussed and examined extensively within psychology and other disciplines. The present study investigated (1) the associations of IU, trait worry, and GAD status to a negative risk orientation, trait curiosity, indecisiveness, perceived constraints, self-oriented and socially prescribed perfectionism, intolerance of ambiguity, the need for predictability, and the need for order and structure and (2) whether IU is a unique correlate of trait worry and of the presence versus absence of Probable GAD, when overlap with other uncertainty-relevant constructs is accounted for. N = 255 adults completed self-report measures of the aforementioned constructs. Each of the constructs was significantly associated with IU. Only IU, and a subset of the other uncertainty-relevant constructs were correlated with trait worry or distinguished the Probable GAD group from the Non-GAD group. IU was the strongest unique correlate of trait worry and of the presence versus absence of Probable GAD. Indecisiveness, self-oriented perfectionism and the need for predictability were also unique correlates of trait worry or GAD status. Implications of the findings are discussed, in particular as they pertain to the definition, conceptualization, and cognitive-behavioral treatment of IU in GAD.     

Worry and Rumination in Generalized Anxiety Disorder and Obsessive Compulsive Disorder

Ample work has already been conducted on worry and rumination as negative thought processes involved in the etiology of most of the anxiety and mood related disorders. However, minimal effort has been exerted to investigate whether one type of negative thought process can make way for another type of negative thought process, and if so, how it subsequently results in experiencing a host of symptoms reflective of one or the other type of psychological distress. Therefore, the present study was taken up to investigate whether rumination mediates the relationship between worry and generalized anxiety disorder (GAD), and between worry and obsessive compulsive disorder (OCD) in two clinical groups. Self-report questionnaires tapping worry, rumination, generalized anxiety disorder (GAD), and obsessive compulsive disorder (OCD) were administered to a clinical sample of 60 patients aged 30–40. Worry, rumination, generalized anxiety disorder (GAD), and obsessive compulsive disorder (OCD) correlated substantially with each other, however, rumination did not mediate the relationship between worry and generalized anxiety disorder (GAD) and between worry and obsessive compulsive disorder (OCD). We also analyzed differences of outcome variables within two clinical groups. These results showed that worry and rumination were significantly different between GAD and OCD groups.     

Cognitive Behavior Therapy for Women With Generalized Anxiety Disorder in the Perinatal Period: Impact on Problematic Behaviors

Generalized anxiety disorder (GAD) is the most frequently diagnosed anxiety disorder among women in the perinatal period (pregnancy to one year postpartum). Recent studies have examined the relationship between problematic behaviors and GAD symptoms. Studies in nonperinatal samples indicate that adults with GAD engage in avoidance and safety behaviors and these behaviors are associated with greater symptom severity. Little research has examined the use of problematic behaviors among pregnant or postpartum women. However, preliminary research suggests that these behaviors may have a negative impact on both anxious women and their children. Our aim was to examine the extent to which women with GAD in pregnancy or the postpartum engage in problematic behaviors and whether cognitive behavioral therapy is effective in reducing these behaviors. Fifty-eight women with GAD in pregnancy or postpartum were recruited from a larger clinical trial (Clinicaltrials.gov ID NCT02850523) evaluating the effectiveness of group-based cognitive behavioral therapy (CBGT) for perinatal anxiety disorders. The results indicated that women with perinatal GAD reported high levels of avoidance and safety behaviors and greater engagement in these behaviors was associated with higher levels of worry and related symptoms. CBGT was effective in reducing GAD symptoms and problematic behaviors and a bidirectional relationship was found between changes in worry and problematic behaviors during treatment. Limitations and future directions are discussed.     

Acceptance and Commitment Therapy for generalized anxiety disorder in older adults: a preliminary report

Some evidence suggests that acceptance-based approaches such as Acceptance and Commitment Therapy (ACT) may be well-suited to geriatric generalized anxiety disorder (GAD). The primary goal of this project was to determine whether ACT was feasible for this population. Seven older primary-care patients with GAD received 12 individual sessions of ACT; another 9 were treated with cognitive-behavioral therapy. No patients dropped out of ACT, and worry and depression improved. Findings suggest that ACT may warrant a large-scale investigation with anxious older adults.     

The role of fear of anxiety and intolerance of uncertainty in worry: An experimental manipulation

The tendency to fear emotional experiences, such as anxiety, may be an important factor in the maintenance of excessive worry, which is the central feature of generalized anxiety disorder (GAD). The goal of the present study was to clarify the role of fear of anxiety in worry by assessing whether the experimental manipulation of fear of anxiety affects worry level. The study also assessed the combined effects of fear of anxious responding and intolerance of uncertainty (a factor already linked to pathological worry) on level of worry by grouping participants according to their tolerance for uncertainty. The results indicated that participants whose fear of anxiety was increased showed higher levels of worry compared to participants whose fear of anxiety was decreased. This finding provides preliminary support for the causal role of fear of anxiety in worry. Moreover, the results showed that increased fear of anxiety in combination with an intolerance for uncertainty led to the highest levels of worry, which suggests that these constructs have an additive effect on worry. The findings lend support to the integration of new conceptualizations of psychopathology with existing models of excessive worry, which could ultimately increase treatment efficacy for GAD.     

Treatment of Comorbid Pica and Generalized Anxiety Disorder: A Case Study

This case report describes the assessment and treatment of a treatment-naïve 36-year-old Hispanic/Latina female with comorbid pica and generalized anxiety disorder (GAD), and iron-deficiency anemia. At the onset of treatment, the client consumed chalkboard chalk and vermiculite from potting soil approximately three times per week and presented with moderate-severity GAD. Assessment and treatment occurred over 24 weekly outpatient individual sessions. Treatment was delivered in concert with medical intervention to address anemia. A cognitive-behavioral case formulation was developed from multiple assessment sources. A process-based cognitive-behavioral therapy (CBT) intervention approach was used to target GAD and pica simultaneously, which included psychoeducation, self-monitoring, arousal reduction skills, cognitive training (reappraisal, distancing), and behavior modification/stimulus control techniques. Barriers to treatment and their solutions are discussed. At the end of treatment, the client demonstrated increased insight and understanding of her worry symptoms and pica behavior, acquired cognitive skills and arousal reduction strategies for managing GAD, and reported less than one episode of pica per week. The identified assessment and treatment approach is worthy of future investigation to inform empirically based treatment development efforts, especially for pica.     

Perseverative thought: a robust predictor of response to emotional challenge in generalized anxiety disorder and major depressive disorder

Generalized anxiety disorder (GAD) and major depressive disorder (MDD) frequently co-occur, yet the reasons for their comorbidity remain poorly understood. In the present experiment, we tested whether a tendency to engage in negative, repetitive thinking constitutes a common risk process for the two disorders. A mixed sample of adults with comorbid GAD–MDD (n = 50), GAD only (n = 35), MDD only (n = 34), or no lifetime psychopathology (n = 35) was administered noncontingent failure and success feedback on consecutive performance tasks. Perseverative thought (PT), measured by negative thought intrusions during a baseline period of focused breathing, emerged as a powerful prospective predictor of responses to this experimental challenge. Participants reporting more frequent negative thought intrusions at baseline, irrespective of thought content or diagnostic status, exhibited a stronger negative response to failure that persisted even after subsequent success. Higher PT over the course of the experiment was associated with later behavioral avoidance, with negative affect and other traits closely linked to anxiety and depression, and with the presence and severity of GAD and MDD. These findings provide evidence for a broadly-defined PT trait that is shared by GAD and MDD and contributes to adverse outcomes in these disorders.     

DSM-IV criteria for generalized anxiety disorder in older adults: distinguishing the worried from the well

This study compared 36 older adults with generalized anxiety disorder (GAD), 22 older adults with subsyndromal anxiety symptoms, and 32 normal controls on criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) for GAD. GAD patients reported more frequent and uncontrollable worry, somewhat different worry content, higher prevalence of most associated symptoms, and more distress or impairment than the subsyndromal group or normal controls. Individuals with subsyndromal anxiety reported more excessive, frequent, and uncontrollable worry than asymptomatic individuals, along with more sleep disturbance, fatigue, and distress or impairment. Results indicate that the key features of late-life GAD are distress and impairment, frequency and uncontrollability of worry, muscle tension, and sleep disturbance and that clinicians treating older adults with GAD should monitor and treat residual symptoms.     

Randomized controlled trial of false safety behavior elimination therapy: a unified cognitive behavioral treatment for anxiety psychopathology

We tested the efficacy of a unified cognitive-behavioral therapy protocol for anxiety disorders. This group treatment protocol, termed false safety behavior elimination therapy (F-SET), is a cognitive-behavioral approach designed for use across various anxiety disorders such as panic disorder (PD), social anxiety disorder (SAD), and generalized anxiety disorder (GAD). F-SET simplifies, as well as broadens, key therapeutic elements of empirically validated treatments for anxiety disorders to allow for easier delivery to heterogeneous groups of patients with anxiety psychopathology. Patients with a primary anxiety disorder diagnosis (N=96) were randomly assigned to F-SET or a wait-list control. Data indicate that F-SET shows good efficacy and durability when delivered to mixed groups of patients with anxieties (i.e., PD, SAD, GAD) by relatively inexperienced clinicians. Findings are discussed in the context of balancing treatment efficacy and clinical utility.     

Inhibitory control and symptom severity in late life generalized anxiety disorder

Contemporary models of generalized anxiety disorder (GAD) posit that worry functions as an avoidance strategy. During worry, individuals inhibit threat-related imagery in order to minimize autonomic reactivity to phobic topics. This conceptualization of worry suggests a role for the executive system in exerting top-down inhibitory control (IC) over threat processing. We tested the hypothesis that better performance on an IC task would be associated with greater severity of worry and concomitant anxious mood. Forty-three older adults (age 60-77) with GAD completed the Stroop color word task and a battery of self-report symptom measures. Fifteen of the GAD patients were paired with age- and sex-matched non-anxious controls. In the full GAD sample, age-normed t-scores of Stroop performance were positively correlated with measures of worry and trait anxiety, but not anxious arousal or depression. Positive relationships between IC and symptom severity were upheld in the smaller subsample of GAD patients, while in the matched control group, no relationships between Stroop scores and clinical measures were observed. Patients and controls did not differ in Stroop performance. In the context of a disorder-specific tendency to make maladaptive use of executive functions, better IC may be associated with more severe symptomatology.     

Brief Cognitive-Behavioral Therapy for Anxious Youth: Feasibility and Initial Outcomes

We developed and evaluated a brief (8-session) version of cognitive-behavioral therapy (BCBT) for anxiety disorders in youth ages 6 to 13. This report describes the design and development of the BCBT program and intervention materials (therapist treatment manual and child treatment workbook) and an initial evaluation of child treatment outcomes. Twenty-six children who met diagnostic criteria for a principal anxiety diagnosis of separation anxiety disorder, generalized anxiety disorder, and/or social phobia were enrolled. Results suggest that BCBT is a feasible, acceptable, and beneficial treatment for anxious youth. Future research is needed to examine the relative efficacy of BCBT and CBT for child anxiety in a randomized controlled trial.     

Evaluating the cognitive avoidance model of generalised anxiety disorder: Impact of worry on threat appraisal, perceived control and anxious arousal

Generalised anxiety disorder (GAD) is characterised by persistent and uncontrollable worry. According to the cognitive avoidance theory of GAD, worry may function as an affective dampening strategy motivated by intolerance of negative emotional states. By facilitating avoidance of more distressing cognitions and associated affect, worry is said to preclude modification of the fear representation in memory, maintaining threat associations and perpetuating further anxiety and worry. The present study evaluated these assumptions in a treatment-seeking GAD sample. Sixty-one participants were randomly allocated to conditions in which they were instructed to worry, imaginally process or relax in response to an anxiety trigger. Results supported the detrimental impact of worry, showing maintained threat expectancies and decreased control perceptions compared to other modes of processing. However, skin conductance level increased as a function of worry and there was no suggestion that worry suppressed affective responding. These findings highlight the need for clarification of the mechanisms involved in the maintenance of threat associations and worry in GAD.     

The impact of pretrauma analogue GAD and posttraumatic emotional reactivity following exposure to the September 11 terrorist attacks: a longitudinal study

The relation between analogue generalized anxiety disorder (GAD) assessed the day before the events of September 11, 2001 (9/11) and long-term outcome was examined in 44 young adults who were directly exposed the following day to the terrorist attacks in New York City. After controlling for high exposure to the attacks, preattack analogue GAD was associated with greater social and work disability, loss of psychosocial resources, anxiety and mood symptoms, and worry, but not symptoms of posttraumatic stress, assessed 12 months after 9/11. Fear and avoidance of emotions assessed 4 months after 9/11 statistically mediated the relation between preattack analogue GAD and social and work disability, loss of psychosocial support, mood and anxiety symptoms, and worry at 12-month follow-up. Avoidance of emotions 4 months after 9/11 also mediated the relation between preattack analogue GAD and posttraumatic stress symptoms 12 months after 9/11.     

Experience and appraisal of worry among high worriers with and without generalized anxiety disorder

Recent research has revealed that a large number of highly worried individuals do not qualify for a diagnosis of generalized anxiety disorder (GAD). This raises the intriguing question of why some high worriers are more impaired and distressed by their worrying than others, particularly when the severity of their worry is the same. The present investigation sought to address this question by examining whether GAD and non-GAD high worriers differ in their actual worry experiences, their subjective appraisals of worry experiences, or both experiences and appraisals of worry. GAD and non-GAD worriers, selected for matching levels of trait worry severity, completed an attention-focus task with thought sampling before and after a brief worry induction. They also completed questionnaires assessing their experiences during and after the worry induction, as well as their general beliefs about worry. GAD worriers experienced less control over negative intrusive thoughts immediately after worrying, reported greater somatic hyperarousal following worry, and endorsed several negative beliefs about worry more strongly than their worry-matched controls. Results suggest that GAD is associated with unique experiences and appraisals that distinguish it from other forms of severe worry.     

Generalisierte Angststörung

The core features of generalized anxiety disorder (GAD) are excessive worry about various topics which are perceived as uncontrollable and mostly last for at least 6 months. Worrying is accompanied by a number of symptoms (e.g. muscle tension and irritability). Various etiological models suggest that avoidance of internal processes (e.g. cognitive, emotional, and physical) by worrying is central to the development and maintenance of GAD. Empirically well supported cognitive-behavioral interventions are worry exposure, applied relaxation, treating metacognitions, intolerance of uncertainty and negative problem orientation. Initial studies indicate the efficacy of mindfulness and acceptance-based approaches as well as psychodynamic approaches to treat GAD. The present article reports central diagnostic procedures, important differential diagnoses and illustrates actual (psycho) therapeutic treatment options.     

Evidence-based psychological treatments for late-life anxiety

This project identified evidence-based psychotherapy treatments for anxiety disorders in older adults. The authors conducted a review of the geriatric anxiety treatment outcome literature by using specific coding criteria and identified 17 studies that met criteria for evidence-based treatments (EBTs). These studies reflected samples of adults with generalized anxiety disorder (GAD) or samples with mixed anxiety disorders or symptoms. Evidence was found for efficacy for 4 types of EBTs. Relaxation training, cognitive-behavioral therapy (CBT), and, to a lesser extent, supportive therapy and cognitive therapy have support for treating subjective anxiety symptoms and disorders. CBT for late-life GAD has garnered the most consistent support, and relaxation training represents an efficacious, relatively low-cost intervention. The authors provide a review of the strengths and limitations of this research literature, including a discussion of common assessment instruments. Continued investigation of EBTs is needed in clinical geriatric anxiety samples, given the small number of available studies. Future research should examine other therapy models and investigate the effects of psychotherapy on other anxiety disorders, such as phobias and posttraumatic stress disorder in older adults.     

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.     

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.