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Review For reprint orders, please contact [email protected] Cognitive behavioral psychotherapy for generalized anxiety disorder: a primer Thane M Erickson and Michelle G Newman† Overview of cognitive behavioral therapy Generalized anxiety disorder is a highly debilitating psychologic disorder associated with cognitive, affective, behavioral and physiologic forms of rigidity and dysfunction. Chronic and uncontrollable worry, a future-oriented and highly negative form of verbal thought, is its hallmark symptom. Cognitive behavioral therapy, the most well-established psychologic treatment for generalized anxiety disorder, entails techniques designed to target and reduce dysfunction in each of these mutually interrelating domains. This review serves as an introduction to cognitive behavioral therapy for generalized anxiety disorder, including conceptualization, treatment methods and evidence for efficacy. Future directions for augmenting treatment efficacy are also discussed. Elaboration regarding treatment components Expert Rev. Neurotherapeutics 5(2), 247–257 (2005) CONTETNS Conclusion Expert opinion Five-year view Information resources Key issues References Affiliations † Author for correspondence The Pennsylvania State University, Department of Psychology, University Park, PA 16802 3103, USA Tel.: +1 814 863 1148 Fax: +1 814 863 7002 [email protected] KEYWORDS: cognitive behavioral therapy, generalized anxiety disorder, relaxation techniques, worry www.future-drugs.com Generalized anxiety disorder (GAD) originally emerged as a diagnostic entity in the 1980 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) – III [1], identified by a constellation of symptoms including anxious apprehension, muscle tension, autonomic over arousal and hypervigilance. GAD evolved from a conceptualization as a residual category to its current status in the DSM-IV-TR as a debilitating standalone psychiatric disorder [2]. Its quintessential symptom is a chronic and uncontrollable worry, a verbal-linguistic form of future-oriented and threat-related mentation. Diagnostic criteria include the presence of excessive, uncontrollable worry and anxiety regarding several topics for more days than not over a duration 6 or more contiguous months, as well as at least three out of six attendant cognitive and somatic symptoms such as restlessness, fatigability, impaired concentration, irritability, muscle tension and sleep disturbance. Symptoms must cause clinically significant distress or impaired functioning and not be due to a pre-existing medical condition or substance-induced state. GAD is relatively widespread with a 12-month prevalence of 3.1% and lifetime prevalence of 5.1% [3,4]. Furthermore, although GAD is one 10.1586/14737175.5.2.247 of the most frequently comorbid disorders with mood and other anxiety disorder [5,6], it often temporally precedes comorbid conditions and leads to serious impairment even without comorbidity [4,7,8]. For such reasons, as well as its common early onset and chronicity [9], some anxiety experts have argued for GAD as the basic anxiety disorder or vulnerability [10]. In addition to symptoms enumerated in the DSM, research has linked GAD to a number of specific dysfunctions and common sequelae associated with the disorder. For instance, relative to nonanxious control participants, GAD patients have consistently demonstrated precognitive attentional biases in which they automatically allocate attention toward threatening stimuli or information [11,12], as well as interpretive cognitive biases marked by negative perceptions of affectively neutral, ambiguous information [13,14]. Such findings attest to the manner in which people with GAD view the world as intrinsically dangerous. Also, whereas disorder-relevant stimuli provoke sympathetic nervous system activation across most anxiety disorders, experimental studies demonstrate that the GAD-central cognitive process of worry decreases cardiovascular reactions to © 2005 Future Drugs Ltd. ISSN 1473-7175 247 Erickson & Newman fear-relevant imagery [15,16]; this suggests that worry inhibits emotional processing [17], the theorized process whereby modifying fear structures in memory requires physiologic activation and habituation as individuals repeatedly confront feared situations (i.e., in exposure therapy). Such findings are consistent with GAD psychophysiologic and ambulatory monitoring studies suggesting decreased variability of the autonomic nervous system (i.e., restricted heart rate variability) [18,19], apparently due to a deficiency in cardiac vagal tone that also underlies precognitive biases [20]. Other notable physiologic processes similarly differentiate GAD patients from normal controls: GAD and worry are associated with heightened left frontal β cortical activation [21], and increased left posterior cortex γ activation (commonly activated for negative affect in general), in particular [22]. Lastly, it should be further noted that individuals with GAD utilize an inordinate amount of healthcare services and exhibit impairment independent of other disorders [23–25]; GAD and chronic anxiety may even function as a susceptibility factor for problems such as chronic fatigue syndrome, cerebrovascular disease and atherosclerosis, as well as for ischemic heart, gastrointestinal, hypertensive and respiratory diseases [26–29]. Furthermore, worry appears to predict coronary heart disease [30], as well as immune parameters [31]. Despite the numerous documented symptoms and associated disability of GAD, it remains one of the least researched anxiety disorders and often goes undetected or misdiagnosed by primary care physicians [32]. Moreover, cognitive behavioral therapy (CBT) – the most consistently empirically supported psychosocial treatment for GAD – has not received adequate dissemination to healthcare providers. Hence, this review serves as an introduction to cognitive behavioral conceptualizations and psychotherapy techniques for GAD, as well as a brief review of its efficacy and promising directions in increasing therapeutic effects. Overview of cognitive behavioral therapy Cognitive behavioral conceptualizations of GAD As previously noted, GAD’s diagnostic criteria and commonly observed extradiagnostic problems suggest that GAD involves dysregulation of multiple cognitive, physiologic and behavioral systems. This appraisal dovetails with the conceptualization of GAD according to various cognitive and behavioral theories, which attempt to explain the reciprocal and dynamic inter-relations between cognitive, affective-physiologic and behavioral domains in maladaptive cycles. Although there does not exist one monolithic, definitive formulation of GAD, several traditional and contemporary models theorize ways in which worry and anxiety are maintained; as described later in this review, these theorized models also indicate which factors treatment should target. Classical Pavlovian learning theory describes pathologic anxiety as an unconditioned response (e.g., extreme autonomic arousal) that becomes a conditioned response to previously neutral or relatively benign stimuli (e.g., insects: conditioned stimulus) when paired with temporally contiguous 248 presentations of an unconditioned stimulus (e.g., physical threat). Whereas this model straightforwardly pertains to phobias, the conditioned stimuli of GAD appear as an increasingly broad set of possible threats. Traditional models of Skinnerian or operant conditioning focus on environmental contingencies (presence or absence of reward or punishment) that are assumed to differentially reinforce behaviors (i.e., increase or decrease the likelihood of the behavior in the future). This formulation was extended by Mowrer’s two-factor theory, which suggests that attempts to avoid anxiety cues or feared stimuli negatively reinforce such behaviors by preventing discomfort, thereby perpetuating them. Thus, anxiety is maintained by failure to remain in situations in which people may otherwise unlearn associations between anxiety and feared stimuli. Whereas contemporary theories of GAD tend to view anxiety as, in part, a learned response maintained by avoidance, they focus more explicitly on the GAD-central process of worry and attempt to explain more precisely the role of cognitions in perpetuating distress. For example, Borkovec and colleagues propose a theory of worry as cognitive avoidance [17]. Based on experimental evidence of worry inhibiting unpleasant imagery and somatic arousal, it appears that individuals with GAD use worry to avoid negative emotional experience. Since feared events rarely occur, and because of the emotion-restricting properties of worry, the worry sequence is negatively reinforced or strengthened in memory as a coping strategy. Anxious people subsequently fail to attend to, and learn from, current emotional experience. Dugas, Ladouceur and colleagues also conceptualize cognitive avoidance as important in GAD, but their model gives a central and possibly causal role to intolerance of uncertainty (IOU) in worry [33]. Given clinical anecdotes of GAD patients that prefer negative to ambiguous outcomes, as well as robust correlational and experimental relations between IOU and worry [33], individuals with GAD appear uniquely vulnerable to negative perceptions of uncertainty, using worry to cope with and avoid states of uncertainty. According to the model, this somewhat successful cognitive avoidance of uncertainty both reinforces worry and decreases opportunities to learn that some uncertainty is normal, perpetuating both IOU and worry; furthermore, hypothesized poor problem-solving ability and beliefs about benefits of worry perpetuates this process. Lastly, Wells’ cognitive model of GAD emphasizes the role of metacognitions about worry (i.e., beliefs about worry itself ) in the disorder’s maintenance [34]. This model distinguishes between Type 1 and 2 worries, with the former pertaining to feared external events and bodily states and the latter pertaining to higherorder worries about the danger and uncontrollability of worrying. Additionally, this model ascribes a central role to beliefs about the supposed benefits of worry (e.g., ‘worrying keeps me ready for the worst’). According to the model, beliefs about the positive aspects of worry lead people with GAD to worry when faced with stressors, causing subsequent distress; during a worry episode, negative meta-beliefs about Expert Rev. Neurotherapeutics 5(2), (2005) Cognitive behavioral psychotherapy for GAD worry are activated (e.g., ‘worrying will make me go crazy’), which often leads to ineffective coping strategies such as avoidance of stressors or attempts to suppress unwanted thoughts, eliciting further distress and seemingly confirming catastrophic beliefs about worry. If distress abates, such individuals may misattribute any positive outcomes to worrying, reinforcing this strategy. In summary, although cognitive behavioral theories of GAD highlight unique factors, they share a common focus on the use of worry as a self-perpetuating avoidance strategy and means of coping with unknown future outcomes. They also suggest relationships between worry, behavior and physiology: worry may contribute to physiologic responses (i.e., muscle tension), triggering additional worry (e.g., ‘what if I can’t control my own bodily reactions?’) and negative affect, which patients often attempt to control by further worrisome cognition or behavioral avoidance of the fear-provoking situations, again strengthening the worry response. In summary, negative and self-perpetuating spiraling interactions between multiple domains are believed to comprise GAD. Overview of treatment components & general approach Due to the inter-related types of dysfunction in GAD, CBT often incorporates multiple treatment components to target each of these aspects individually as well as in tandem (i.e., ameliorating one domain may benefit another domain, as when learning to create physiologic relaxation responses indirectly decreases anxious cognition) [35]. Although specific interventions flow from particular models of GAD, CBT typically involves techniques derived from cognitive and behavioral theories of the disorder. Cognitive therapy (CT) techniques address the role of threat-based mentation by teaching identification of automatic thoughts and core beliefs (namely, about self, others and the world), challenging maladaptive beliefs about worry (i.e., regarding putative benefits and dangers of worry) and creating alternative interpretations, and logical analysis of worry probability via evidence-gathering and behavioral tests of negative predictions [36]. Also, based on the behavioral assumption that learning adaptive coping methods to replace avoidant ones will reduce the need for worry, patients learn a variety of techniques for inducing relaxed states and mitigating the autonomic inflexibility characteristic of GAD: diaphragmatic breathing (DB) exercises, pleasant imagery, progressive muscle relaxation (PMR) and applied relaxation (AR) [37]. Furthermore, patients learn to approach feared situations or states in order to extinguish learned associations between these stimuli and anxiety. They may use self-control desensitization (SCD) to imaginally expose themselves to a hierarchy of avoided or feared cues and mental images, as well as actual exposure to feared situations in daily life [38]. This also permits practice application of relaxation methods under conditions of anxiety. CBT also entails behavioral techniques such as stimulus control methods and behavioral activation (reintroduction of reinforcing or enjoyable activities) to counteract comorbid depressive anhedonia. www.future-drugs.com Overall, although psychotherapy of GAD poses greater difficulties than other anxiety disorders because of its diffuse nature and lack of a focalized feared object or situation, CBT equips patients with a plethora of resources for coping with anxiety. By learning new coping strategies, patients begin to associate cues previously linked to conditioned anxiety responses with new, anxiety-reducing responses. Such counter-conditioning, when applied efficiently as anxiety cues are detected, terminates worry spirals before they become excessive. The use of multiple techniques also fosters flexible responding to combat systemic behavioral, cognitive and physiologic rigidity observed in GAD; therapists take an experimental or scientific approach by encouraging patients to test techniques for themselves and document symptom reduction. In this manner, patients become increasingly competent at living in the present moment and finding intrinsic enjoyment in life activities, rather than rigidly devoting cognitive resources to possible future catastrophes. Additionally, as a relatively brief intervention (i.e., typically ≤12 sessions), CBT assumes that most of the therapeutic work occurs outside the psychotherapy session in the context of applying techniques to lived struggles. Therefore, homework assignments pertaining to technique rehearsal and application occupy a central place in the treatment. Elaboration on CBT techniques will follow documentation of its treatment efficacy. Brief review of efficacy Due to inter-related types of dysfunction in GAD, efficacious treatment is paramount. Currently, CBT remains the most consistently empirically supported form of psychotherapy for GAD [39]. Since the initial controlled psychotherapy trial for GAD in 1984 [40], 17 similar studies have examined the efficacy of treatments broadly subsumed under the rubric of CBT, in that their treatment packages incorporated various cognitive and/or behavioral components. A recent meta-analysis of 13 of these controlled outcome studies and review reached several important conclusions pertaining to efficacy [41,42]. First, CBT leads to significant symptom change and maintains such improvement for up to 1 year post termination, sometimes leading to further gains after treatment termination; also, clinically significant change occurs in the majority of the few studies testing for it. Second, CBT shows consistent superiority over no-treatment and pill placebo-control conditions, as well as some evidence of outperforming nondirective therapy, placebo psychotherapy, pill placebo and psychoanalytic psychotherapy [43,44]. Also, CBT is well liked by patients and shows evidence of low attrition rates. Moreover, despite some findings of slight relative superiority for behavior therapy versus cognitive therapy or vice versa, analyses of studies employing shared outcome assessments suggest that CBT tends to demonstrate the largest effect sizes relative to its constituent components. The six most recent CBT outcome studies further buttress the efficacy of cognitive and behavioral techniques for GAD [45–50]. Lastly, it bears noting that successful (i.e., diminishing GAD symptoms) CBT also reduces comorbid diagnoses [51,52], diminishes attentional biases toward threat [53,54], and normalizes 249 Erickson & Newman the γ activation in posterior cortical regions [22]. Nonetheless, despite CBT’s status as the gold-standard psychosocial treatment for GAD, an average of only approximately 50% of GAD patients across controlled treatment outcome studies have demonstrated clinically significant benefits (i.e., achieving symptom levels comparable with nondiagnosed individuals), suggesting considerable need for augmenting efficacy [41,55,56]. Elaboration regarding treatment components Behavioral therapy techniques Early cue detection & self monitoring Correct self assessment of cognitive, affective, behavioral and physiologic symptoms forms the cornerstone of CBT for GAD. Since GAD patients often commence treatment without awareness of the specific linkages between their daily activities and symptoms in these domains, they must improve at recognizing symptoms with their daily antecedents and consequents as a prerequisite for applying specific CBT techniques to reduce anxiety. In particular, patients are taught to begin monitoring anxiety levels and their ebb and flow throughout the day, often at regular time intervals (e.g., on the hour) or when they perform common actions (e.g., every time they leave a room). They are directed to monitor situational or external anxietyprovoking cues (e.g., conditions of heightened ambiguity, timepressured work demands and relationship conflicts), as well as internal cues (e.g., thoughts, imagery, emotions and somatic states), in order to facilitate greater moment-to-moment awareness of the interaction between multiple cues and concomitant worry states. Patients typically benefit from concrete self-monitoring homework assignments involving daily diaries in which they note specific worries and the situations with which they co-occur. During sessions, the therapist may begin to facilitate cue detection by having patients worry out loud or imagine themselves in a worry-provoking situation, taking note of idiosyncratic internal cues. In this manner, patients learn to become aware of the covariation between anxious mentation, bodily states, behaviors and situations, ultimately in the service of catching anxiety spirals early in the sequence and applying coping strategies. Additionally, they gain practice at attending to current experience rather than distracting from it via worry. Relaxation techniques Since GAD is characterized by systemic rigidity across multiple domains, CBT supplies patients with an array of techniques for deployment against anxiety, in an attempt to increase their range and flexibility of behavioral responses. Often, patients first learn and practice relaxation techniques during sessions to ensure their correct usage and provide initial demonstrations of immediate anxiety reduction. Diaphragmatic breathing exercises Experimental evidence suggests that breathing from the diaphragm stimulates the relaxation response of the parasympathetic nervous system [57,58], whereas shallow thoracic or chest breathing often increases sympathetic nervous system 250 responding and induces concomitant physiologic arousal [59,60]. Many anxious individuals chronically overbreathe or engage in chest breathing [61,62]. Accordingly, GAD patients are taught to practice slow, rhythmic, regular breathing from the diaphragm region, which should noticeably rise and fall as they breathe. As they inhale and expand their diaphragm, they may silently count numerically, followed by exhalation accompanied by the silent use of a relaxation cue word (e.g., one, relax; two, relax). Consistent with the tenet of CBT that direct in-session experience and therapist modeling provide the ideal first foray into new skill acquisition, patients are directed to engage in both forms of breathing during training sessions, noting associated increases and decreases in momentary anxiety levels. Additionally, patients receive instruction to practice DB daily. Progressive muscle relaxation Taking as its point of departure the pioneering work of Jacobson [63] and Wolpe [64] supporting the use of muscle relaxation to produce a relaxed lifestyle and create a physiologic response antagonistic to anxiety, CBT often incorporates PMR techniques. In PMR, therapists lead patients to tense and release a series of 16 major muscle groups (i.e., right hand and forearm, left hand and forearm, right biceps, left biceps, upper face, central face, lower face, neck, chest, shoulders and upper back, abdomen, right thigh, left thigh, right calf, left calf, right foot and left foot) [65]. Therapists direct patients to focus attention on and tense each muscle group for several seconds, which both provides practice at attentional engagement (as opposed to diffuse worry) and allows for a stronger physiologic relaxation response when instructed to fully and instantaneously let go of each muscle group. Once they release muscle contraction, they are directed to focus exclusively on the sensations of warmth and relaxation in targeted muscle groups. If patients experience their mind wandering, they practice gently refocusing, sometimes with the aid of a relaxation cue word (e.g., tranquil) as in meditation exercises. Additionally, patients gain, via the juxtaposition of tension and release, a greater ability to identify bodily anxiety. Once patients have sufficiently mastered 16-group PMR (by twice-daily practice for 15 min), the 16 groups collapse to seven and then four groups (i.e., left and right hands and arms, neck and face, trunk and abdomen, and both legs and feet). Eventually, patients are taught relaxation-by-recall, actively engaging memories of muscle release sensations to achieve the relaxation response without actual muscle contraction. Additionally, as patients become increasingly skilled at letting go of physical tension, they practice letting go of anxious imagery or thoughts. Traditional muscle relaxation also provides an excellent forum for teaching mindfulness, an acceptance of current experience rather than using worry to restrict emotion [66]. Paradoxically, some patients have learnt to associate letting go, itself, with anxiety, and consequently encounter relaxation-induced anxiety (RIA) as a result of relaxation training [67]. Although RIA predicts a negative treatment Expert Rev. Neurotherapeutics 5(2), (2005) Cognitive behavioral psychotherapy for GAD response for CBT, several strategies may diminish or circumvent it [68]. Patients may repeatedly utilize brief PMR applications repeatedly when encountering anxiety cues throughout the day in place of twice-daily practice. Alternatively, treatment of RIA may be conceptualized as graduated exposure as with any other feared stimuli or situation; patients increasingly expose themselves to stronger relaxation sensations and tolerate anxiety responses until they peak in intensity and gradually dissipate within and across repeated exposures. Moreover, reframing relaxation as a process rather than an absolute end state targets perfectionistic patients’ tendency to work so diligently to relax that, ironically, they essentially produce tension. Such strategies eliminated the predictive relationship between early RIA and treatment outcome in one study [67]. Guided imagery exercises Due to the fact that GAD patients’ internal experience is frequently populated by worrisome thoughts [69–71] and that worry involves abstract, verbal-linguistic thought as distinct from imagery process [72], CBT incorporates pleasant imagery exercises as an additional relaxation method, based on basic research showing that imagery generates the same pattern of physiologic activation that the actual occurrence of an event causes [73,74]. Anxious individuals induce state relaxation by visualizing a person, location or situation previously coupled with a sense of security, replete with associated sensory stimuli (e.g., sights, smells, sounds and tactical aspects). For instance, individuals choosing a beach scene are directed to envision the sounds of the surf, texture of the sand underfoot, smell of salt, and feel of the sun and breeze. Additionally, visual imagery techniques combine well with PMR in that patients may visualize their worries floating away, akin to a cloud or balloon, as they let go of muscle tension. Applied relaxation Once patients progress to the point of proficiency at particular relaxation techniques during treatment sessions and daily rehearsal periods, they utilize applied relaxation, the real-life application of these skills toward intervention when detecting shifts in anxiety level. As they become adept at scanning thoughts and bodily states for initial anxiety cues, they marshal their newly-learned relaxation skills to directly reduce distress. AR encompasses cue-controlled applied relaxation (i.e., using a cue word previously paired with relaxation responses to re-engage such responding), differential relaxation training (i.e., practicing muscle relaxation when walking in order to discriminate adaptive levels of muscle tension from excessive levels), and application of PMR before, during and after stressful events. Insofar as patients master AR, they accomplish generalization of relaxation skills to actual day-to-day problematic routines to counteract their habitual style of rigidity and apprehension. Self-control desensitization GAD is less amenable to exposure therapy than more circumscribed anxiety disorders such as specific or social phobias. www.future-drugs.com However, one particularly useful technique in treating GAD – self-control desensitization – functions as both a form of imaginary exposure and means for application of relaxation skills in the context of purposively induced anxiety. SCD was created to provide a form of desensitization suitable for diffuse anxiety conditions lacking obvious core feared stimuli [38]. Whereas systematic desensitization typically involves identification of phobic stimuli and construction of an exhaustive hierarchy of increasingly anxiety-producing external situations, SCD involves more flexibility in identification of situations and less elaborate hierarchy construction. Patients isolate various situations that typically elicit worry, as well as the particular behavioral, imaginary, cognitive and physiologic cues for anxiety spirals. Once patients have designated various situations as generally mild, moderate or severe, they begin with SCD techniques on the lowest hierarchy level. First, they rehearse PMR to achieve a satisfactorily relaxed state. Subsequently, they vividly imagine themselves in an anxiety-evocative situation, experiencing anxiety cues, until they detect actual internal anxiety cues and arousal. At this point, they relax away the anxiety by envisaging themselves successfully coping with the circumstance until anxiety cues desist, at which point they persist in imagining their relaxed and effective responses to the situation (∼20 s). Lastly, patients terminate the mental image of successful coping and concentrate only on relaxation sensations (20 s). In this manner, patients are afforded opportunities to both encounter increasingly stressful situations imaginally and learn to reduce the actual anxiety elicited by these images. Furthermore, imagining adaptive coping to feared situations fortifies positive memories instead of worry-relevant ones. Stimulus control techniques Due to the fact that individuals with GAD have learned to worry in many situations, these various contexts may take on anxiety-provoking meanings, becoming worry triggers in their own right. In order to diminish associations between these cues and worry, stimulus control techniques attempt to quarantine worry within a specific time of day and location. Patients schedule a daily half-hour period devoted exclusively to worry; this time should not coincide with work or other leisure activities. When patients detect incipient worry and anxiety, they deliberately attempt to postpone worry until their scheduled worry period, utilizing self-talk reminding them that they may worry as much as desired later. If unable to curtail a worry episode before it spirals considerably, patients go directly to their elected worry setting until the anxiety becomes manageable, at which point they may return to their prior activity. Despite the fact that GAD patients perceive worry as uncontrollable, stimulus control techniques teach them that they possess more than a modicum of control over when and how they worry. Although these methods have not been evaluated in isolation from aggregate CBT treatment packages (i.e., in dismantling study designs), college samples of chronic worriers have reported beneficial effects [75]. 251 Erickson & Newman Cognitive therapy techniques In addition to behavioral methods, cognitive therapy techniques directly address GAD patients’ chronic misestimates of future risks, maladaptive beliefs concerning worry and uncertainty, and allocation of cognitive resources to negative material and interpretations. The various models of CT for GAD have several features in common. First, as part of the aforementioned self-monitoring and early cue detection, patients become increasingly aware of the content of their worries and/or beliefs about worry. Second, using a Socratic (i.e., nonconfrontational) style of questioning and intersubjective collaboration between therapist and patient, CT helps patients re-evaluate the reasonability of worries or costs and benefits of beliefs regarding worry. Third, once these worries or meta-worries have been articulated, therapists encourage patients to challenge these beliefs by behavioral tests, undergoing situations that provide for disconfirmation of maladaptive beliefs. Patients collect data by monitoring worries, bodily states and outcomes for feared events, which provide material with which to challenge maladaptive beliefs. Despite similarities between varieties of cognitive therapy for GAD, characteristic foci should be noted for respective models. For instance, the traditional CT approach to anxiety disorders [36], derived from the cognitive therapy of depression, directly evaluates and challenges the reasonableness of specific negative beliefs. By way of logical analysis, patients challenge and disconfirm their negative core beliefs and fears about self (e.g., ‘what if I’m a total failure?’), others (‘what if others disapprove of my actions?’) and the world (e.g., ‘what if terrorists ruin the economy?’). CT specifies a number of common inaccurate thought styles that cause or exacerbate emotional distress (e.g., thinking in all-or-none categories, making gross generalizations from single instances of failure, or attending exclusively to negative information to the exclusion of anomalies); as patients learn to recognize these logical inaccuracies, they take their worries less literally, considering them instead as hypotheses to be tested via direct experience. Importantly, therapists help patients generate multiple alternative predictions and perspectives to replace unrealistic ones (e.g., ‘I will seek and eventually obtain a job’ vs. ‘I may never be hired’); patients must, however, generate interpretations that are at least as believable as their worries. If patients initially show difficulty with this exercise, therapists may suggest less anxiety-relevant topics initially; for instance, patient and therapist may jointly brainstorm both desirable and undesirable aspects of owning a cellular phone, winning the lottery or being raised as an only child. Ultimately, once patients generate a sufficient number of realistic, flexible and adaptive alternatives to their fears, they apply these selfstatements as a coping strategy when they detect worry or encounter stress in daily life. Based on observations that individuals engaged in excessive worry tend to grossly overestimate threat and underestimate coping resources (e.g., ‘what if I displease my boss and can’t cope with the consequences?’) [76], Borkovec and Newman suggest that patients should generate concrete 252 negative predictions and compare them with an objective diary record of the frequency with which negative events occur, as well as the extent to which they cope successfully [77]. Based on patients’ own self-collected data, therapists help patients more accurately evaluate probabilities of both possible negative events and their competence to cope during the relatively rare times that they occur. They learn that the frequency of worrying hardly coincides with frequency of feared events. When such events do occur, worry fails to prevent them; when these events do not occur, patients actually create undue distress (e.g., overarousal and hypervigilance) as a result of worry. Whereas traditional CT directly challenges patients’ pathologic worries and core negative beliefs about self and the world, several models of GAD suggest the importance of challenging other belief structures. Based on the IOU model discussed above, CT may confront GAD patients’ beliefs about uncertainty [78]. Some patients may prove resistant to standard CT because, even when worries are shown to be unreasonable, there still exists some chance, if minimal, that negative outcomes may occur (i.e., some uncertainty remains). If patients can decrease the extent to which they fear and avoid uncertainty, they have less reason to worry as a means of controlling it. This treatment teaches patients to distinguish between worries about current difficulties versus those about possible problems [47,49]. After learning problem-solving skills, patients apply these skills to the current worries as a coping method more adaptive than worry, even if uncertain about the outcome. For worries pertaining to possible future problems, they undergo imaginary exposure to raise the ability to tolerate, rather than avoid, uncertain states and situations. Patients also re-examine their positive beliefs regarding worry. Overall, patients learn that uncertainty, to some extent, is a normal, integral part of life and need not be eradicated, especially by detrimental strategies such as worry. Wells’ metacognitive model of GAD [34] also has implications for conducting CT. Specifically, treatment first challenges negative perceptions of worry as uncontrollable, often by having the patient find instances when worry has been controllable, as when distracted from a worry episode. The aforementioned stimulus control exercises may serve as worry postponement experiments for patients to learn that they possess some control over worry, contrary to beliefs. Next, CT challenges beliefs about the danger of worry via psychoeducation about how worry is less harmful than negative appraisals of it and maladaptive coping; patients may also test out their negative beliefs by attempting to purposely lose control when worrying, observing the consequences. Subsequently, patients identify and challenge beliefs about supposed benefits of worry; this occurs by comparing written negative predictions with actual outcomes in order to suggest that worries are inaccurate and therefore unhelpful. Also, patients may make active attempts to worry and then observe whether situational outcomes Expert Rev. Neurotherapeutics 5(2), (2005) Cognitive behavioral psychotherapy for GAD favor worrying or not. Lastly, this treatment provides coping strategies alternative to worry, such as imagining favorable outcomes to worries instead of catastrophes. In sum, CT teaches individuals with GAD to identify the links between worrisome cognition and negative affect, helps them develop more flexible thought styles, and encourages them to live in the present moment. Whereas worry often serves as a control strategy to prevent or anticipate negative future outcomes, it creates the illusion that threat is imminent, engendering bodily tension. In contrast, CT helps patients recognize and avoid only realistic fears, as opposed to all conceivable catastrophes. Although chronic worriers prove skilled at arguing for the benefits or accuracy of their worries, analysis of worries and data from approaching feared situations to test the veracity of their fears (i.e., behavioral experiments) compels patients to shift to present-moment focus and cope with stressors when they arise, rather than pre-emptively. Conclusion In conclusion, CBT arms individuals suffering from GAD with a wealth of theory-based, empirically supported techniques for managing and reducing their chronic worry and anxiety. Primary care physicians and other healthcare providers are encouraged to screen appropriately for chronic and rigid worry indicative of GAD to facilitate accurate diagnosis in these individuals; commonly comorbid conditions such as other anxiety disorders, major depressive disorder and irritable bowel syndrome may be mistakenly assigned primary diagnostic status. Additionally, due to the fact that many GAD patients report a lifelong history of excessive worry, they often do not seek treatment for this symptom. However, since CBT techniques are relatively easy to implement and well tolerated by patients, greater dissemination is merited. Nevertheless, further research will endeavor to obtain greater symptom reduction for individuals caught in the negative cognitive-affective-behavioral-somatic spirals distinguishing GAD. Expert opinion Despite the fact that GAD often goes undiagnosed by primary care physicians and mental health service providers, we view it as a serious condition that hinders individuals from fully living in the present and is associated with a variety of emotional and somatic forms of dysregulation; such a conclusion derives from evidence of significant functional impairment, highly chronic course, health consequences, medical service utilization and other concomitant problems. As noted, approximately half of patients treated fail to achieve clinically significant results, despite the superiority of CBT. Therefore, while we recommend CBT as the first-line intervention for GAD, we emphasize the necessity for further research into the basic mechanisms of the disorder and treatment development. Additionally, although CBT typically provides a brief, technique-focused intervention, some GAD patients may require a longer treatment duration that explicitly addresses patients’ www.future-drugs.com interpersonal problems and interpersonal dynamics in the patient–therapist relationship. Since factors such as interpersonal problems, symptom severity, chronicity and personality disorders predict adverse psychotherapy response for anxiety disorder patients [79], therapists working with GAD patients manifesting these characteristics should strive to maintain a positive therapeutic alliance in the service of preventing premature termination before patients have learned sufficiently to apply anxiety-reduction methods. Also, although we have exclusively discussed CBT, we must note that meta-analytic findings suggest that CBT is only slightly and nonsignificantly more efficacious than pharmacotherapy in reducing anxious symptomatology [80]. However, in this analysis, CBT manifested a significantly greater reduction of depressive symptoms and consistent maintenance of treatment gains, whereas the benefits of medication declined upon their discontinuation. Additionally, benzodiazepines, the traditional pharmacologic agents in treating GAD, may pose risks over long-term usage [81]. For these reasons, as well as our experience suggesting that antianxiety medication may serve the purpose of avoidance of feared states for some patients and thus thwart necessary fear exposure, we recommend CBT as a treatment that equips patients to approach and cope successfully with feared situations, fostering internal locus of control. Nonetheless, we recognize the appropriate use of psychotropic medication and their advantages when combined with CBT for many patients, especially for those who are invested in pharmacologic intervention and are able to adhere to the regimen. Five-year view As stated, much room exists for augmenting the efficacy of the current CBT package. One particularly promising direction pertains to interpersonal and emotion regulation problems. Individuals with GAD have endorsed relatively high levels of interpersonal problems [82] and college students with GAD symptoms have shown problems in interpersonal perception and behavior [83]; furthermore, GAD patients may be identified by different clusters of interpersonal problems [84], some of which have predicted poor treatment response at follow-up in a therapy outcome study [46]. Additionally, worry inhibits emotional processing [15], and individuals with GAD symptoms have shown difficulty understanding and regulating emotion [85–87], as well as relatively high displays of negative emotion in reaction to self-disclosing confederates [88]. Due to these consistent findings, the GAD research group at Pennsylvania State University (PA, USA) are testing whether the inclusion of therapy components targeting interpersonal problems and emotional experiencing will enhance the ameliorative effect of CBT. Initial findings suggest promise [87,89], but it may be several years before the project reaches completion and data are fully analyzed. Of note is that psychodynamic treatment, traditionally addressing these types of concerns more explicitly than CBT, has been adapted for GAD, also yielding positive initial findings [90]. Furthermore, several 253 Erickson & Newman researchers are examining the efficacy for GAD of treatment that integrates CBT with mindful acceptance of current experience and committed action toward valued goals [91]. Continued research into CBT incorporating constructs such as mindfulness, metacognitions and intolerance of uncertainty may also foster development of ways to increasingly ameliorate suffering for persons with GAD. • Newman MG. Generalized anxiety disorder. In: Effective Brief Therapies: a Clinician’s Guide. Hersen M, Biaggio M (Eds). Academic Press, CA, USA, 157–178 (2000). Another overview of CBT for GAD, with application to a specific clinical case. Information resources • Heimberg RG, Turk CL, Mennin DS (Eds). Generalized Anxiety Disorder: Advances in Research and Practice. Guilford Press, NY, USA (2004). The following include a sampling of important articles on CBT for GAD: A review of recent developments in theory and treatment for GAD, including cognitive behavioral and other perspectives. Key issues • Generalized anxiety disorder (GAD) is a difficult anxiety disorder to treat due to its diffuse nature and lack of a specified feared situation or object. Cognitive behavioral therapy forms the gold-standard psychosocial treatment for GAD and meets criteria as an empirically supported intervention according to the American Psychological Association Division 12 (Clinical Psychology) Task Force on Promotion and Dissemination of Psychological Procedures. Diaphragmatic breathing, pleasant imagery exercises, progressive muscle relaxation and applied relaxation help patients achieve states of deep cognitive and physiologic relaxation, increase present-moment focus and furnish them with strategies to cope with life stressors on a daily basis. Self-control desensitization and other forms of imaginary exposure to feared imagery reduce anxiety while providing opportunities for rehearsal and direct application of relaxation techniques. Cognitive therapy techniques involve identification of anxiety-producing worries and beliefs about worry and uncertainty, challenging such thoughts via logical analysis and information gathering and creating alternative perspectives and self-statements that foster cognitively flexible responding. On average, treatment studies suggest that approximately half of GAD patients show high end-state functioning in response to cognitive behavioral therapy, so future basic and applied research must ascertain what additional treatment components, refinements or idiographic modifications may further enhance efficacy. • • • • • References Papers of special note have been highlighted as: • of interest •• of considerable interest 1 2 3 4 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Third Edition. American Psychiatric Association, Washington DC, USA (1980). American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 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Prac. 10(3), 222–230 (2003) Affiliations • • Thane M Erickson, MS Doctoral Candidate in Clinical Psychology, The Pennsylvania State University, Department of Psychology, University Park, PA 16802 3103, USA Tel.: +1 814 863 0115 Fax: +814 863 7002 [email protected] Michelle G Newman, PhD Associate Professor of Psychology, The Pennsylvania State University, Department of Psychology, University Park, PA 16802 3103, USA Tel.: +1 814 863 1148 Fax: +1 814 863 7002 [email protected] 257