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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
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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
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ISSN 1473-7175
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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
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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
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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.
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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
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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
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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
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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.
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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].
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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
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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’
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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:
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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]
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