Cognition About Cognition: Metacognitive Therapy and Change in Generalized Anxiety Disorder and Social Phobia

Metacognitive theory and therapy views the persistence of negative beliefs and thoughts as a result of metacognitions controlling cognition. This paper describes, with reference to the treatment of generalized anxiety disorder (GAD) and social phobia, how metacognition contributes to cognitive stability and to change. Metacognitive therapy offers a level of formulation and intervention that does not focus predominantly on challenging the content of negative thoughts and beliefs that are emphasized in traditional cognitive therapy. The focus of treatment in GAD is on erroneous beliefs about worry and unhelpful mental regulation strategies. In treating social phobia, a greater emphasis is placed on modifying attention and worry processes and on configuring processing during and after behavioral experiments.     

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.     

“It's wrong to relax,you have to be on the go,go, go,all the time”: Emotional transformation in a case of emotion-focused therapy for generalised anxiety disorder

Generalised anxiety disorder (GAD) is a highly prevalent, chronic and impairing disorder. The aim of this study was to qualitatively describe the transformation in emotional processing across 16 sessions of a successful emotion-focused therapy (EFT) treatment for GAD. A theoretical framework derived from the EFT model of in-session emotional transformation proposed by Pascual-Leone and Greenberg was used as the basis for qualitative analysis. Additionally, the Classification of Affective Meaning States, the Client-Expressed Arousal Scale-III and the Client Emotional Productivity Scale-Revised were utilised by observer–raters to classify moment-by-moment shifts in client affective-meaning states, emotional arousal and emotional productivity. Results supported the emotion transformation model. The client presented in a state of poorly differentiated but highly aroused distress provoked by identifiable interpersonal and intrapersonal triggers. Emotional and behavioural avoidance provoked by fear of pain was evident. Accessing core pain and responding to attendant needs with compassion and protective anger was shown to facilitate the higher order emotional processing states of grief, relief and agency. Implications are proposed, including that addressing core emotional vulnerability may be a critical intervention in the successful treatment of 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.     

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.     

Integrating Religion and Spirituality Into Treatment for Late-Life Anxiety: Three Case Studies

Generalized anxiety disorder (GAD) is common in older adults and, although cognitive behavioral therapy (CBT) is an efficacious treatment for late-life GAD, effect sizes are only moderate and attrition rates are high. One way to increase treatment acceptability and enhance current cognitive behavioral treatments for GAD in older adults might be to incorporate religion/spirituality (R/S). The cases presented here illustrate the use of a 12-week modular CBT intervention for late-life anxiety, designed to allow incorporation of R/S elements in accordance with patient preferences. The three women treated using this protocol chose different levels and methods of R/S integration into therapy. All three women showed substantial improvement in worry symptoms, as well as a variety of secondary outcomes following treatment; these gains were maintained at 6-month follow-up. These preliminary results suggest that the incorporation of R/S into CBT might be beneficial for older adults with GAD. Strengths, limitations, and future directions 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.     

An open trial of an acceptance-based behavior therapy for generalized anxiety disorder

Research suggests that experiential avoidance may play an important role in generalized anxiety disorder (GAD); see . Expanding our conceptualization of and treatment for generalized anxiety disorder: Integrating mindfulness/acceptance-based approaches with existing cognitive-behavioral models. Clinical Psychology: Science and Practice, 9, 54-68, for a review). Therefore, a treatment that emphasizes experiential acceptance, as well as intentional action, may lead to both reduced symptomatology and improved quality of life and functioning for individuals with this chronic disorder. In an open trial of a newly developed acceptance-based behavior therapy for GAD, 16 treated clients demonstrated significant reductions in clinician-rated severity of GAD and reports of anxiety and depressive symptoms and fear and avoidance of their internal experience, as well as significant improvements in reports of quality of life, at both posttreatment and 3-month follow-up. Directions for future treatment development and research 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.     

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.     

Contextual conditioning in rats as an animal model for generalized anxiety disorder

Animal models of psychiatric disorders are important translational tools for exploring new treatment options and gaining more insight into the disease. Thus far, there is no systematically validated animal model for generalized anxiety disorder (GAD), a severely impairing and difficult-to-treat disease. In this review, we propose contextual conditioning (CC) as an animal model for GAD. We argue that this model has sufficient face validity (there are several symptom similarities), predictive validity (it responds to clinically effective treatments), and construct validity (the underlying mechanisms are comparable). Although the refinement and validation of an animal model is a never-ending process, we want to give a concise overview of the currently available evidence. We suggest that the CC model might be a valuable preclinical tool to enhance the development of new treatment strategies and our understanding of GAD.     

Exposing Worry’s Deceit: Percentage of Untrue Worries in Generalized Anxiety Disorder Treatment

Theories of cognitive therapy have long proposed that those with generalized anxiety disorder (GAD) have inaccurate expectations. By challenging them with objective evidence, symptoms are thought to decrease. To test these premises, this study used ecological momentary assessment (EMA) during the Worry Outcome Journal (WOJ) treatment to determine the percentage of GAD worries that did not come true. We then analyzed the association between participants’ untrue worry percentages and GAD symptom change across treatment. Twenty-nine participants with GAD recorded worries when prompted for 10 days, reviewed them online nightly, and tracked their worry outcomes across 30 days. These recordings were then coded by independent raters. Analyses applied bias-correct bootstrapping path analysis on slopes extracted from longitudinal linear mixed models. Primary results revealed that 91.4% of worry predictions did not come true. Higher percentages of untrue worries significantly predicted lower GAD symptoms after treatment, as well as a greater slope of symptom reduction from pre- to post-trial. Participants’ average expected likelihoods of worries coming true were much greater than actual observed likelihoods. The most common percentage of untrue worries per person was 100%. Thus, worries in those with GAD were mostly inaccurate. Greater evidence of this inaccuracy predicted greater improvement in treatment. As theorized, disconfirming false expectations may significantly contribute to treatment’s effect.     

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.     

Randomized controlled trial on the effectiveness of metacognitive therapy and intolerance-of-uncertainty therapy for generalized anxiety disorder

This randomized controlled trial compared the effectiveness of metacognitive therapy (MCT) and intolerance-of-uncertainty therapy (IUT) for generalized anxiety disorder (GAD) in an outpatient context. Patients with GAD (N = 126) consecutively referred to an outpatient treatment center for anxiety disorder were randomly allocated to MCT, IUT, or a delayed treatment (DT) condition. Patients were treated individually for up to 14 sessions. Assessments were conducted before treatment (pretreatment), after the last treatment session (posttreatment), and six months after treatment had ended (follow-up). At posttreatment and follow-up assessments, substantial improvements were observed in both treatment conditions across all outcome variables. Both MCT and IUT, but not DT, produced significant reductions in GAD-specific symptoms with large effect sizes (ranging between 0.94 and 2.39) and high proportions of clinically significant change (ranging between 77% and 95%) on various outcome measures, and the vast majority of the patients (i.e., 91% in the MCT group, and 80% in the IUT group) no longer fulfilled the diagnostic criteria for GAD. Results further indicate that MCT produced better results than IUT. This was evident on most outcome measures, and also reflected in effect sizes and degree of clinical response and recovery.     

Cognitive-Behavioral Treatment of Generalized Anxiety Disorder

Generalized Anxiety Disorder (GAD) can be treated effectively with cognitive-behavioral therapy. When working with clients who have GAD, therapy can focus on four central areas that help to promote therapeutic change. The initial focus of therapy is on developing a sound therapeutic alliance and educating the client about anxiety symptoms. Skills training focuses on relaxation training and cognitive changes that can help clients confront their worries in a constructive manner. Then, exposure to internal and external aspects of the anxiety can help clients test and refine their coping skills. Finally, because of the chronic nature of GAD, relapse prevention strategies can be used to help maintain treatment gains over time. These strategies allow a broad but flexible treatment plan that can be adapted to the unique needs of each individual client.     

Implicit theories of intelligence and IQ test performance in adolescents with Generalized Anxiety Disorder

During the past decade, several studies have reported positive effects of cognitive-behavioral therapy (CBT) in the treatment of children and adolescents with mental disorders. One of the most important CBT interventions is to teach children and adolescents to challenge negative thoughts that lead to maladjusted behaviors. Based on the implicit theories of intelligence framework, the main purpose of this study was to test whether an incremental theory manipulation could be used to affect IQ test performance in adolescents with Generalized Anxiety Disorder (GAD). Results showed that patients demonstrated enhanced IQ performance and experienced less state anxiety when they were exposed to an incremental theory of intelligence manipulation. Our findings suggest that incremental theory manipulation provides a useful cognitive strategy for addressing school-related anxiety in adolescents with mental disorders such as GAD.     

An Open Trial of Group Acceptance and Commitment Therapy With an Adjunctive Mobile App for Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is a common and debilitating condition. Effective treatments exist, but they are time- and resource-intensive. This study tested the initial efficacy and acceptability of a novel treatment protocol designed to increase efficiency: acceptance and commitment therapy (ACT) taught in groups and through an adjunctive mobile app. Participants were 21 individuals with GAD who received six weeks of 2-hour group ACT sessions as well as access to an adjunctive ACT mobile app. Significant improvements occurred in worry, anxiety, social functioning, and depression as well as relevant processes (psychological inflexibility, anxiety-related cognitive fusion). In-the-moment improvements were also observed in symptoms and ACT processes immediately after completing mobile app sessions. Treatment was perceived as credible and acceptable overall. However, rates of reliable and clinically significant change were low, and app usage did not correlate with change in worry. Overall, this study suggests that an efficient, brief ACT group intervention combined with a mobile app may lead to improvements in GAD but may not be sufficient for clinically significant change. A detailed overview of the treatment is included, and guidance for clinicians interested in implementing this protocol is discussed.     

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.     

Baseline Client Interpersonal Agency Moderates the Indirect Effect of Treatment on Long-term Worry in Variants of CBT for Generalized Anxiety Disorder

In a recent trial for generalized anxiety disorder (GAD), cognitive-behavioral therapy (CBT) integrated with motivational interviewing (MI) promoted more long-term worry reduction than CBT alone (Westra, Constantino, & Antony, 2016). A follow-up analysis found that CBT vs. MI-CBT clients evidenced greater increases in friendly submissiveness (FS) across treatment, which in turn promoted lower long-term worry (Constantino, Romano, Coyne, Westra, & Antony, 2018). It was unsurprising that traditional directive CBT promoted more FS than when person-centered MI was integrated; however, given that problematic low agency characterizes GAD, that greater FS promoted better outcome was unexpected. To further unpack this unexpected result, we tested the following moderated mediation hypothesis: for clients with more vs. less problematic low agency at baseline, CBT would still promote more in-session FS than MI-CBT, but this increase would in turn predict increased worry over follow-up. Clients receiving CBT (n = 43) or MI-CBT (n = 42) rated their interpersonal problems at baseline and their worry after treatment and across 12-month follow-up. Therapists rated clients’ in-session FS multiple times. As predicted, multilevel modeling revealed that for clients with more problematic low agency, CBT vs. MI-CBT facilitated greater FS, which in turn related to increased worry across follow-up. For clients with more problematic high agency, CBT’s facilitation of greater FS related to reduced worry across follow-up. A baseline interpersonal problem characteristic of GAD may have implications for treatment matching and for appreciating different pathways to long-term improvement, or deterioration, for different GAD subgroups.