Preliminary evidence for an emotion dysregulation model of generalized anxiety disorder

Three studies provide preliminary support for an emotion dysregulation model of generalized anxiety disorder (GAD). In study 1, students with GAD reported heightened intensity of emotions, poorer understanding of emotions, greater negative reactivity to emotional experience, and less ability to self-soothe after negative emotions than controls. A composite emotion regulation score significantly predicted the presence of GAD, after controlling for worry, anxiety, and depressive symptoms. In study 2, these findings were largely replicated with a clinical sample. In study 3, students with GAD, but not controls, displayed greater increases in self-reported physiological symptoms after listening to emotion-inducing music than after neutral mood induction. Further, GAD participants had more difficulty managing their emotional reactions. Implications for GAD and psychopathology in general are discussed.     

A follow-up study of cognitive bias in generalized anxiety disorder

Patients with generalized anxiety disorder (GAD) without concurrent depression (n = 11) and normal controls (n = 17) were tested twice, about 2 months apart, on a modified Stroop colour-naming task, which presented anxiety-related, depression-related and neutral words in masked and unmasked exposure conditions. GAD patients received cognitive behaviour therapy in the test-retest interval, and were also retested at follow-up, about 20 months after initial testing. GAD patients showed interference in colour-naming negative words across both masked and unmasked conditions before treatment, but not post-treatment, compared with controls. Reduced interference effects of masked threat words over time correlated with reduced ratings of anxious thoughts at post-treatment, and at follow-up, in GAD patients. Thus, the preconscious bias for threat information in GAD appears to vary over time in association with changes in anxious thoughts and worries.     

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.     

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.     

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.     

Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder

Mindfulness-based stress reduction (MBSR) has been reported to reduce anxiety in a broad range of clinical populations. However, its efficacy in alleviating core symptoms of specific anxiety disorders is not well established. We conducted a randomized trial to evaluate how well MBSR compared to a first-line psychological intervention for social anxiety disorder (SAD). Fifty-three patients with DSM-IV generalized SAD were randomized to an 8-week course of MBSR or 12 weekly sessions of cognitive-behavioral group therapy (CBGT). Although patients in both treatment groups improved, patients receiving CBGT had significantly lower scores on clinician- and patient-rated measures of social anxiety. Response and remission rates were also significantly greater with CBGT. Both interventions were comparable in improving mood, functionality and quality of life. The results confirm that CBGT is the treatment of choice of generalized SAD and suggest that MBSR may have some benefit in the treatment of generalized SAD.     

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.     

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.     

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.     

Influence of co-morbid generalized anxiety disorder, panic disorder and personality disorders on the outcome of cognitive behavioural treatment of obsessive-compulsive disorder

This study examined co-morbid generalized anxiety disorder and/or panic disorder and personality disorders as predictors of treatment outcomes in adult outpatients with obsessive-compulsive disorder. The patients received exposure with response prevention (ERP) treatment with the addition of either elements of cognitive therapy (ERP+CT) or relaxation training (ERP+REL). It was hypothesized that the addition of cognitive interventions would yield better treatment outcomes for patients with co-morbid generalized anxiety disorder and/or panic disorder. It was also hypothesized that patients with any personality disorder would show less treatment gains in both conditions. Using intention-to-treat criteria, patients with generalized anxiety disorder and/or panic disorder co-morbidity showed less treatment gains at post-treatment across both treatment conditions. This group showed significantly more treatment gains in the ERP+CT condition at the post-treatment and the 12-month follow-up assessments compared with patients in the ERP+REL condition. However, this was not significant when comparing treatment completers. Patients with a co-morbid Cluster A or B personality disorder showed significantly less treatment gains in both treatment conditions at the 12-month follow-up assessment. Among treatment completers, patients with a Cluster C personality disorder showed significantly better outcomes at the post-treatment assessment in the ERP+REL treatment condition. These results, clinical implications, and the importance of further investigations are discussed.     

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.     

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.     

The predictive capacity of self-reported motivation vs. early observed motivational language in cognitive behavioural therapy for generalized anxiety disorder

ABSTRACT

Client motivation to change is often considered a key factor in psychotherapy. To date, research on this client construct has largely relied on self-report, which is prone to response bias and ceiling effects. Moreover, self-reported motivation has been inconsistently related to treatment outcome. Early observed client in-session language may be a more valid measure of initial motivation and thus a promising predictor of outcome. The predictive ability of motivational factors has been examined in addiction treatment but has been limited in other populations. Addressing this lack, the present study investigated 85 clients undergoing cognitive behavioural therapy (CBT) alone and CBT infused with motivational interviewing (MI-CBT) for severe generalized anxiety disorder. There were two aims: (1) to compare the predictive capacity of motivational language vs. two self-report measures of motivation on worry reduction and (2) to examine the influence of treatment condition on motivational language. Findings indicated that motivational language explained up to 35% of outcome variance, event 1-year post-treatment. Self-reported motivation did not predict treatment outcome. Moreover, MI-CBT was associated with a significant decrease in the most detrimental type of motivational language compared to CBT alone. These findings support the importance of attending to in-session motivational language in CBT and learning to respond to these markers using motivational interviewing.