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.     

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.     

Behavioral Experiments for Intolerance of Uncertainty: Challenging the Unknown in the Treatment of Generalized Anxiety Disorder

Intolerance of uncertainty (IU) is implicated in the development and maintenance of generalized anxiety disorder (GAD). Although an efficacious cognitive-behavioral treatment (CBT) targeting IU and associated factors has been established, approximately 20–30% of participants do not achieve full remission by posttreatment. IU remains elevated in these individuals. In addition, GAD treatments need greater parsimony and efficiency. To that end, we developed a novel, focused CBT protocol exclusively targeting IU via behavioral experiments. Treatment consists of three modules applied over 12 sessions: (a) psychoeducation and uncertainty awareness training, (b) behavioral experiments targeting IU, and (c) relapse prevention. The present article describes each treatment component, as well as additional considerations for therapists. We conducted a preliminary investigation of efficacy with seven (N = 7) participants with a primary diagnosis of GAD. Results indicated substantial decreases in GAD symptoms, general psychopathology, and IU by posttreatment that were generally maintained at 6-month follow-up. Six of seven participants demonstrated moderate to high end-state functioning at posttreatment and 6-month follow-up. Research and clinical implications are discussed.     

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.     

A Contemporary View of Applied Relaxation for Generalized Anxiety Disorder

Applied relaxation (AR), originally developed by Lars-Göran Öst, is a long-standing, efficacious treatment for generalized anxiety disorder (GAD). While newer treatments are continuing to be developed, AR remains one of the most efficacious treatments for GAD. However, AR has received less in-depth attention more recently, particularly in terms of potential mechanisms of action. This article is written to honor the development and history of AR and to highlight the ways that it has continued to be adapted. In this article, AR treatment strategies are presented, which include: noticing early signs of anxiety, learning relaxation skills, and applying relaxation at the first sign of anxiety. Then, additional adaptations to AR are presented along with recommendations of how AR may be enhanced by understanding potential mechanisms of change. Finally, recommendations are made for the continued evolution of AR as a powerful and efficacious treatment for GAD.     

Cognitive Mediators of Treatment for Social Anxiety Disorder: Comparing Acceptance and Commitment Therapy and Cognitive-Behavioral Therapy

Objective

To assess the relationship between session-by-session mediators and treatment outcomes in traditional cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for social anxiety disorder.

Method

Session-by-session changes in negative cognitions (a theorized mediator of CBT) and experiential avoidance (a theorized mediator of ACT) were assessed in 50 adult outpatients randomized to CBT (n = 25) or ACT (n = 25) for DSM-IV social anxiety disorder.

Results

Multilevel modeling analyses revealed significant nonlinear decreases in the proposed mediators in both treatments, with ACT showing steeper decline than CBT at the beginning of treatment and CBT showing steeper decline than ACT at the end of treatment. Curvature (or the nonlinear effect) of experiential avoidance during treatment significantly mediated posttreatment social anxiety symptoms and anhedonic depression in ACT, but not in CBT, with steeper decline of the Acceptance and Action Questionnaire at the beginning of treatment predicting fewer symptoms in ACT only. Curvature of negative cognitions during both treatments predicted outcome, with steeper decline of negative cognitions at the beginning of treatment predicting lower posttreatment social anxiety and depressive symptoms.

Conclusions

Rate of change in negative cognitions at the beginning of treatment is an important predictor of change across both ACT and CBT, whereas rate of change in experiential avoidance at the beginning of treatment is a mechanism specific to ACT.     

Changes in Anxiety Control Beliefs Following a Brief CBT Treatment and Their Association With Anxiety Symptom Reduction

Anxiety control beliefs (i.e., beliefs regarding one’s ability to cope with external, fear-inducing threats and internal reactions to those perceived threats) have been found to negatively predict anxiety symptoms in children and adults and to be modifiable by cognitive-behavioral therapy for anxiety disorders. The current study examines whether changes in anxiety control beliefs were seen following a brief, intensive treatment for specific phobias, and whether those changes were associated with improvements in the targeted phobia and comorbid anxiety disorder symptoms. Participants were 135 children and adolescents (M age = 9.01 years, 49% male) who received one-session treatment (OST) with or without parental involvement for their primary specific phobia. Results indicated that self-reported anxiety control beliefs significantly increased following treatment and that these increases significantly predicted reductions in specific phobia severity and symptoms of comorbid anxiety disorders 6 months and 1 year following treatment. Findings illustrate that involvement in a single 3-hour OST was associated with changes in anxiety control beliefs and demonstrate the potential importance of targeting control beliefs in pediatric anxiety treatment.     

Generalized Anxiety Disorder in Hispanics: Symptom Characteristics and Prediction of Severity

Literature suggests that an increasing number of Hispanic people suffer with GAD, and possible associated problems include high costs for treatment and elevated risk of severe impairment. The current study examined components of anxiety, as measured by currently available assessment instruments in both English and Spanish languages, among bilingual Hispanic individuals with GAD. Participants completed all instruments in both languages. Relations between these self-report measures and clinician-rated GAD severity were also studied. In factor analyses, the Spanish measures yielded two factors, the first of which included all instruments assessing physiological components of anxiety and one content specific measure of worry. The second factor included one worry scale and one trait anxiety scale. The English measures yielded a single factor solution. Regression analyses revealed that for the English measures, the BAI and PSWQ were statistically significant predictors of GAD severity. For the Spanish measures, the BAI was the only statistically significant predictor.     

Systems-Centered Therapy: A Protocol for Treating Generalized Anxiety Disorder

The systems-centered short-term therapy protocol was adapted and applied in three single case studies with generalized anxiety disorder (GAD) patients in a ten-session individual treatment over a two week period. All three subjects showed substantial improvement and no longer met diagnostic criteria post-treatment. Changes were maintained at follow up both six months and one year later. These results are promising and suggest the importance of further research on SCT as a viable, alternative treatment for generalized anxiety disorder.     

Treatment of Adolescent Panic Disorder: A Nonrandomized Comparison of Intensive Versus Weekly CBT

This study compared the relative efficacy of intensive versus weekly panic control treatment (PCT) for adolescent panic disorder with agoraphobia (PDA). Twenty-six adolescents participated in weekly sessions and 25 received intensive treatment involving daily sessions. Both groups demonstrated significant and comparable reductions in panic disorder severity and general anxiety symptoms, which maintained over time. Participants receiving weekly treatment showed significant decreases in depressive symptoms, whereas those in the intensive program reported no change. Findings support the efficacy of the intensive approach for adolescent PDA, but suggest that adolescents receiving intensive treatment may benefit from a brief course of additional weekly sessions.     

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.     

Cognitive Behavioural Therapy and Applied Relaxation for Generalized Anxiety Disorder: A Time Series Analysis of Change in Worry and Somatic Anxiety

The present study examined symptom change profiles in patients with generalized anxiety disorder (GAD) receiving either cognitive behavioural therapy (CBT) or applied relaxation (AR). It was hypothesized that (a) changes in worry would uniquely predict changes in somatic anxiety for most participants receiving CBT and (b) changes in somatic anxiety would uniquely predict changes in worry for most participants in the AR condition. Twenty participants (CBT n = 10; AR n = 10) completed daily ratings of worry and somatic anxiety during therapy, and multivariate time series analysis was used to assess the causal impact of each variable on the other. The hypotheses were not supported because we found no evidence of a match between individual symptom change profiles and treatment condition. Rather, a bidirectional relationship between worry and somatic anxiety was observed in 80% of participants receiving CBT and 70% of participants receiving AR. When only treatment responders were considered, 83% of participants receiving CBT and 86% of those receiving AR had such a bidirectional effect. The findings are discussed in terms of models of psychopathology that posit dynamic interactions between symptom clusters and in terms of the value of examining treatment mechanisms at the individual level.     

A Preliminary Examination of the Acceptability,Feasibility, and Effectiveness of a Telehealth Cognitive-Behavioral Therapy Group for Social Anxiety Disorder

In light of the growing interest in, and need for, the telehealth delivery of health care, additional research is needed on the acceptability and effectiveness of these types of interventions. This study examined the acceptability, feasibility, and preliminary effectiveness of an adapted telehealth-delivered group cognitive-behavioral therapy (CBT) intervention for adults with social anxiety disorder (SAD). This report describes the adaptation and subsequent implementation of an 8-week telehealth-delivered group treatment designed to reduce symptoms of SAD. Specific adaptations for delivering treatment during the COVID-19 pandemic and the subsequent enactment of social distancing measures are discussed. Posttreatment data indicated that the intervention was feasible to implement in an outpatient mental health clinic, acceptable to participants, and associated with reduction in symptoms of social anxiety, general anxiety, depression, and stress.     

Psychometric Properties of the Generalized Anxiety Disorder Questionnaire for DSM-IV Among Four Racial Groups

The Generalized Anxiety Disorder Questionnaire-IV (GAD-Q-IV) is a self-report diagnostic measure of generalized anxiety disorder. Previous studies have established the psychometric properties of the GAD-Q-IV, revealing excellent diagnostic specificity and sensitivity as well as good test–retest reliability and convergent and discriminant validity (Newman et al., 2002). Recent analyses with other measures of anxiety symptoms have revealed differences across racial or national groups. Given that the GAD-Q-IV was tested primarily on Caucasians (78%), the purpose of this study was to demonstrate the psychometric properties of the GAD-Q-IV across four racial groups: African American, Caucasian, Hispanic/Latino, and Asian. A student sample of 585 undergraduate psychology students completed the GAD-Q-IV as well as other measures of anxiety symptoms. A clinical replication sample included 188 participants who completed the GAD-Q-IV as part of a larger psychotherapy study. Results indicated excellent and very similar factor structures in the student sample and similar psychometric properties in both samples across the racial groups. Implications for the use of the GAD-Q-IV across racial groups are discussed.     

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.     

Distress and Avoidance in Generalized Anxiety Disorder: Exploring the Relationships with Intolerance of Uncertainty and Worry

Theory and research suggest that treatments targeting experiential avoidance may enhance outcomes for patients with generalized anxiety disorder (GAD). The present study examined the role of experiential avoidance and distress about emotions in a treatment-seeking sample with a principal diagnosis of GAD compared with demographically matched nonanxious controls and sought to explore their shared relationship with two putative psychopathological processes in GAD: intolerance of uncertainty and worry. Patients with GAD reported significantly higher levels of experiential avoidance and distress about emotions compared with nonclinical controls while controlling for depressive symptoms, and measures of these constructs significantly predicted GAD status. Additionally, experiential avoidance and distress about anxious, positive, and angry emotions shared unique variance with intolerance of uncertainty when negative affect was partialed out, whereas only experiential avoidance and distress about anxious emotions shared unique variance with worry. Discussion focuses on implications for treatment as well as future directions for research.     

Working Memory and Motor Activity: A Comparison Across Attention-Deficit/Hyperactivity Disorder,Generalized Anxiety Disorder,and Healthy Control Groups

Converging findings from recent research suggest a functional relationship between attention-deficit/hyperactivity disorder (ADHD)-related hyperactivity and demands on working memory (WM) in both children and adults. Excessive motor activity such as restlessness and fidgeting are not pathognomonic symptoms of ADHD, however, and are often associated with other diagnoses such as generalized anxiety disorder (GAD). Further, previous research indicates that anticipatory processing associated with anxiety can directly interfere with storage and rehearsal processes of WM. The topographical similarity of excessive motor activity seen in both ADHD and anxiety disorders, as well as similar WM deficits, may indicate a common relationship between WM deficits and increased motor activity. The relationship between objectively measured motor activity (actigraphy) and PH and visuospatial WM demands in adults with ADHD (n = 21), adults with GAD (n = 21), and healthy control adults (n = 20) was examined. Although all groups exhibited significant increases in activity from control to WM conditions, the ADHD group exhibited a disproportionate increase in activity, while activity exhibited by the GAD and healthy control groups was not different. Findings indicate that ADHD-related hyperactivity is uniquely related to WM demands, and appear to suggest that adults with GAD are no more active relative to healthy control adults during a cognitively demanding laboratory task.     

Information Processing and Decision-Making in Pathological Worriers and their Potential Role in Mechanisms of Generalized Anxiety Disorder

Systematic information processing and decision-making under uncertainty are key constructs of new conceptions explaining the severity of pathological worry. The current study attempted to analyze their usefulness in subclinical and clinical groups. In the first phase of the study (N = 251) participants were examined with the Penn State Worry Questionnaire (PSWQ), a GP consultationrelated survey, and a screening survey for generalized anxiety disorder (GAD). In the second phase (N = 220), the State-Trait Anxiety Inventory, the PSWQ, and tasks measuring systematic information processing (SIP) versus heuristic reasoning (HR) were applied. In the third phase (N = 60), GAD (n = 30) and healthy control (n = 30) groups were examined with the above methods and the Iowa Gambling Task (IGT). In the low risk group, a relationship between mood and the representativeness heuristic (ρ = 0.50), as well as anchoring and adjustment heuristic (anxiety-related stimuli) was found (ρ = −0.53). In the GAD group, significant correlations between the PSWQ score, the IGT loss avoidance score (ρ = 0.40), and total IGT score (ρ = 0.48) were found. The results did not confirm a particular usefulness of the systematic/heuristic information processing construct in subclinical and clinical groups. Theory-consistent results were rather found in the nonclinical groups. Nevertheless, the data revealed some interesting findings supporting potential explanatory power of some theoretical models.     

Intolerance of Uncertainty Mediates the Relation Between Generalized Anxiety Disorder Symptoms and Anger

Previous research has shown that individuals with generalized anxiety disorder (GAD) report elevated anger compared with nonanxious individuals; however, the pathways linking GAD and anger are currently unknown. We hypothesized that negative beliefs about uncertainty, negative beliefs about worry and perfectionism dimensions mediate the relationship between GAD symptoms and anger variables. We employed multiple mediation with bootstrapping on cross-sectional data from a student sample (N = 233) to test four models assessing potential mediators of the association of GAD symptoms to inward anger expression, outward anger expression, trait anger and hostility, respectively. The belief that uncertainty has negative personal and behavioural implications uniquely mediated the association of GAD symptoms to inward anger expression (confidence interval [CI] = .0034, .1845, P_M = .5444), and the belief that uncertainty is unfair and spoils everything uniquely mediated the association of GAD symptoms to outward anger expression (CI = .0052, .1936, P_M = .4861) and hostility (CI = .0269, .2427, P_M = .3487). Neither negative beliefs about worry nor perfectionism dimensions uniquely mediated the relation of GAD symptoms to anger constructs. We conclude that intolerance of uncertainty may help to explain the positive connection between GAD symptoms and anger, and these findings give impetus to future longitudinal investigations of the role of anger in GAD.     

Willingness to Seek Treatment Among Black Students With Anxiety or Depression: The Synergistic Effect of Sociocultural Factors With Symptom Severity and Intolerance of Uncertainty

Anxiety and depressive disorders are among the most commonly diagnosed psychiatric disorders, yet they remain largely undertreated in the U.S. and Black adults are especially unlikely to seek or receive mental health services. Symptom severity has been found to impact treatment-seeking behaviors as have sociocultural factors. Yet no known research has tested whether these factors work synergistically to effect willingness to seek treatment. Further, emerging data point to the importance of transdiagnostic risk factors such as intolerance of uncertainty (IU). IU may be negatively related to seeking treatment given that Black adults may be uncertain whether treatment might benefit them. Thus, the current study examined the relations between symptom severity/IU and willingness to seek treatment for anxiety/depression problems and the impact of key sociocultural variables (i.e., cultural mistrust–interpersonal relations [CMI-IR], perceived discrimination [PED]) on these relations among 161 (85% female) Black undergraduates. Consistent with prediction, symptom severity was positively related to willingness, but unexpectedly, IU was positively related. There was a significant Symptom Severity × CMI-IR interaction such that severity was positively related to willingness among students with lower cultural mistrust, but not higher mistrust. There were also significant IU × PED interaction such that IU was positively related to willingness among students with lower PED, but not higher PED. Results highlight the importance of considering the interplay between symptom severity, transdiagnostic vulnerability factors, and sociocultural variables when striving to identify factors related to treatment seeking behaviors among anxious and/or depressed Black students.