Psychotherapy for generalized anxiety disorder

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Psychotherapy for generalized anxiety disorder Author Michelle Craske, PhD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Oct 2013. | This topic last updated: Set 10, 2013. INTRODUCTION Generalized anxiety disorder (GAD) is characterized by excessive worry and anxiety that are difficult to control, cause significant distress and impairment, and occur on more days than not for at least six months [1]. Generalized anxiety disorder (GAD) is a relatively common disorder, most often with an adult onset and chronic course [2-5]. GAD can lead to significant impairments in role functioning, diminished quality of life, and high healthcare costs [6,7]. The disorder can be effectively treated with psychotherapy, medication, or a combination of the two modalities. This topic addresses psychotherapy for GAD. Pharmacotherapy for GAD is addressed separately. The epidemiology, pathogenesis, clinical manifestations, course, and diagnosis of GAD are addressed separately. (See "Generalized anxiety disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Pharmacotherapy for generalized anxiety disorder".) OVERVIEW Clinical trials have found cognitive behavioral therapy to be effective for generalized anxiety disorder (GAD) compared to control conditions and other psychotherapies. Evidence from clinical trials of other psychotherapies for GAD is insufficient to recommend their use. Evidence from clinical trials suggests that the combination of cognitive behavioral therapy and either benzodiazepines or sertraline is more effective in GAD than the medications alone. COGNITIVE BEHAVIORAL THERAPY Theoretical foundation Cognitive behavioral therapy (CBT) is based on evidence that shows that persons with generalized anxiety disorder (GAD) engage in overestimations and catastrophizing of negative events; show limited confidence in problem solving; require additional evidence before making decisions; have a low tolerance of uncertainty, an iterative problem-solving style, worry about worry, and numerous behavioral and cognitive strategies that may actually be counterproductive and help maintain the self-perpetuating cycle of worry [8]. In particular, GAD is associated with judgment biases and attentional biases, such as a tendency to interpret ambiguous situations in a threatening manner [9,10], overestimate the likelihood of negative events [11], and over-attend to threatening stimuli, even when the stimuli are not consciously perceived [12]. The automaticity of this pre-attentive bias is likely to lead to the experience of worry and anxiety as being intrusive. GAD is also associated with avoidance behaviors, including excessive preparation (eg, getting to an appointment an hour beforehand to avoid being late), checking behaviors (eg, making sure the children are safe when sleeping), and procrastination [13]. These behaviors are believed to reinforce anxiety and propagate the cycle of worry. In addition, persons with GAD may attempt to control worry by distraction [14]. The relief from distraction, however, is likely to be short-lived [15-17], and attempts to deliberately suppress worry may serve to automatically prime the worry thoughts [16]. Worry may function as an avoidance behavior in and of itself, and in particular, avoidance of fearful imagery and autonomic arousal [18]. The largely verbal, left-hemispheric act of worry is far less autonomically arousing than right-hemispheric, pictorial processing (eg, worrying about childrens safety versus picturing them dead in a car accident) [19]. Verbal or linguistic processing of threat is associated with weaker negative affect [20] and less Section Editor Murray B Stein, MD, MPH Deputy Editor Richard Hermann, MD

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Psychotherapy for generalized anxiety disorder

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autonomic reactivity [21] than imagery based processing of the same threat. Also, chronic worry or GAD is associated with sustained restriction of autonomic reactivity, or less variation in autonomic state [22]. By suppressing catastrophic imagery and associated autonomic activation, worry inhibits access to underlying fear. In other words, worry becomes a form of avoidance. Catastrophic images are presumed to continue to emerge periodically, in turn motivating continued cognitive avoidance in the form of worry. As a result of this negative reinforcement cycle, pre-attentive biases towards threat and further catastrophic images, with the associated drive to shift to worry in order to avoid them, are reinforced. Also characteristic of GAD is low confidence in problem-solving abilities, partially due to worries over making the wrong decision. Patients with GAD prefer to acquire as much evidence as possible before making decisions [23], have a low tolerance for ambiguity [24], and engage in an iterative style of problem solving (ie, generating all possible negative outcomes) [25] compared to nonanxious controls. Such behavioral patterns contribute to distress over decision making and general anxiety. This is compounded by the effects of continuous worry upon ability to concentrate (eg, at work), thereby impairing performance and providing additional sources of worry. Positive and negative metacognitive beliefs about worry promote further worry and rumination [13]. Positive beliefs refer to the positive value of worrying in order to reach solutions or prevent negative events from occurring. Negative beliefs that worrying is uncontrollable and harmful (ie, Im out of control to worry this excessively) appear to more strongly predict pathological worry compared to positive beliefs [26], presumably because the negative beliefs generate worry about worry, attempts to suppress further worry, avoidance behaviors, and reassurance seeking [13]. CBT addresses the various cognitive, behavioral, and physiological features of GAD through a number of strategies. First, overestimations and catastrophizing of negative events are addressed through cognitive skills that encourage evidence-based thinking, which in turn is believed to lessen attentional biases to threat. Deficits in problem solving are targeted through additional cognitive skills that encourage a problem-coping focus, as well as behavioral skills for enhanced decision making and time management. Behavioral practices aim to reduce excessive checking, procrastination, and other worry behaviors, and often include repeated exposure to anxietyprovoking situations. In addition, through repeated exposure to catastrophic images, the emotional response and autonomic arousal subsides, which in turn reduces the drive to shift to excessive worry to avoid such images. Finally, progressive muscle relaxation aims to reduce excessive muscle tension and vigilance to threat. Indications Individuals for whom CBT works best are generally highly motivated and value a problem-solving approach. CBT requires that the patient learns the skills of self-observation and of becoming a personal scientist, cognitive and behavioral coping skills, and to repeatedly practice the skills in anxiety-provoking contexts outside of the therapy setting [27]. It is unclear whether CBT is better suited to individuals from certain cultures. CBT as a general approach is heavily aligned with Europe and North American values of an individuals capacity for change, open self-disclosure, independence, autonomy, and rational thinking [28]. Such values often are at odds with values of harmony, family, and spirituality that are deeply embedded in Asian, Latino, Arabic, African American, and other cultures, which might imply that CBT would be less effective in such populations. However, evidence suggests that CBT for anxiety (although not specifically for GAD) can be effective with Latino and African American groups. Adaptation of the therapy to other cultures has been attempted (eg, greater involvement of family members), but the impact of these modifications is not well understood [29]. Exposure to anxiety-producing situations may be contraindicated for persons with dementia, psychosis, and other thought disorders. In patients with medical conditions potentially exacerbated by high levels of autonomic arousal (eg, certain arrhythmias or high blood pressure), a more graduated approach may be preferable to intensive exposure, with ongoing monitoring of medical status. Assessment An in-depth, structured interview is the first step in establishing diagnostic features and details of associated behaviors (eg, decision-making difficulties) in preparation for psychotherapy. An instrument such as the Anxiety Disorders Interview Schedule, Fourth Edition (ADIS-IV) [30] can be used to collect data on the domains of worry as well as GAD physical symptoms. Such information is particularly helpful for tailoring treatment. As an example, details about the domains of worry will inform the content of cognitive restructuring.

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Psychotherapy for generalized anxiety disorder

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The most useful standardized self-report inventory is the GAD-7 [31], which is a brief scale of frequency of cognitive and somatic symptoms of GAD. Other scales, listed below, provide useful information for treatment planning and are sensitive markers of therapeutic change: Penn State Worry Questionnaire [32] measures the excessiveness and uncontrollable nature of worry. Worry Domains Questionnaire [33] assesses the amount of worry across five domains of everyday concern: relationships, lack of confidence, aimless future, work, and financial issues. Metacognitions Questionnaire [34,35] measures individual differences in a selection of metacognitive beliefs, judgments, and monitoring tendencies involving cognitive confidence, positive beliefs about worry, cognitive self-consciousness, negative beliefs about uncontrollability of thoughts and danger, and beliefs about need to control thoughts. Principles of practice The central focus of CBT for GAD is teaching patients a set of cognitive and somatic coping skills to effectively manage their anxiety as they are repeatedly exposed to anxiety provoking images and activities. More specifically, patients are taught to become personal observers of their anxiety and worry. They learn to implement skills of cognitive restructuring to replace catastrophic appraisals with more evidence-based and coping oriented appraisals. They learn techniques from relaxation training to control excessive levels of tension. Then, patients are encouraged to apply the cognitive and relaxation skills during exposures to images of feared negative events, and to anxiety-provoking situations, as they prevent themselves from engaging in overt and subtle avoidance behaviors. Symptoms of GAD that CBT addresses are: Cognitive symptoms of excessive and uncontrollable worry about a number of different life domains Physical symptoms of motor tension, vigilance, restlessness, inability to relax, poor sleep, and poor concentration Behavioral symptoms of excessive preparation, procrastination, poor decision making, and avoidance Specific techniques CBT is a multimodal intervention for GAD, including patient education, self-monitoring, relaxation training, cognitive restructuring, imagery exposure, exposure to anxiety provoking situations, and relapse prevention. These techniques are described below. Education Treatment begins with education on: Informing and correcting misconceptions regarding anxiety, worry, and associated symptoms Causative factors of pathological worry and anxiety A model of factors that perpetuate GAD The treatment plan and rationale (ie, symptoms of GAD will subside by using evidence-based and coping oriented thinking, by dealing directly with anxiety provoking images and situations, and by learning to relax) Much of this information is integrated in presenting how a pathological cycle of worry and anxiety develops and is maintained in patients lives. Self-monitoring Self-monitoring is introduced in the first treatment session and continues throughout the entire treatment. Learning to observe their reactions from an objective standpoint encourages the patients development as a personal scientist and increases his or her accuracy in self-observation. Self-monitoring allows patients to chart their progress in therapy. Patients keep track of significant episodes of worry on a Worry Record (form 1) to be completed as soon as possible during or after each worry episode. The record provides a description of the cues, maximal distress, and symptoms, thoughts, and behaviors. Patients additionally complete a daily mood record at the end of each day to record overall or average levels of anxiety.

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Relaxation training Relaxation training can be particularly meaningful for GAD patients as they often experience elevated muscle tension and reduced flexibility of autonomic functioning [36]. Relaxation training consists of progressive muscle relaxation (after brief deliberate tension) [37] of all muscle groups of the body in a systematic manner, beginning with 16 muscle groups, and then condensing to 8 muscle groups, and 4 muscle groups. Relaxation training ends with cue-control relaxation, where patients cue themselves to relax by simply repeating a word (such as relax) that has been repeatedly paired with relaxation phases during the preceding weeks of progressive muscle relaxation training. Cue-control relaxation is then used as a coping skill for practicing exposure to anxiety-producing images or situations (also referred to as applied relaxation). Breathing exercises, such as slow, diaphragmatic breathing, may be incorporated into relaxation training. Cognitive restructuring Cognitive restructuring is a set of skills for identifying and modifying misappraisals that contribute to anxiety, including: Patients are shown how anxiety and maladaptive behaviors are generated by overly-negative interpretations of events. Patients are helped to identify errors in thinking (eg, overestimating the probability or valence of negative events) and rigid rules or beliefs that underlie dysfunctional thought patterns. Patients are encouraged to use an empirical approach to examine the validity of thoughts by considering all of the available evidence. Therapists use Socratic questioning to help patients make guided discoveries and question their anxious thinking. Patients then generate alternative interpretations or hypotheses to situations with the help of additional evidence gathered in behavioral practices in anxiety-provoking situations. As an example, a person who typically avoided taking on new responsibilities due to worries about making mistakes was encouraged to take on new responsibilities, to gather evidence on what happens subsequently. He or she learned that mistakes were less frequent than anticipated and did not have negative consequences. Underlying beliefs (eg, I am incompetent) are postulated to change with the patients accrual of evidence that challenges his or her negative thoughts. Cognitive bias modification programs have been developed using paradigms initially developed to assess biases in attention (ie, dot probe) [10]. In the modification programs, individuals are trained to attend to neutral (instead of negative) words or images. Imagery exposure Imagery exposure is designed to help patients tolerate negative affect and autonomic arousal associated with fearful images that they often attempt to avoid through worry [38]. Patients generate hierarchies of fear images related to two or three main areas of worry and are led through systematic exposure to these images. When anxiety elicited by an image is reduced to a mild level, then patients progress to the next image on the hierarchy. Two main versions of imagery exposure have been developed [39,40]. In one version, patients imagine a worst case scenario for 25 to 30 minutes, and then generate alternative outcomes to the scenario. This approach has been shown to be effective for GAD as a standalone treatment in a small randomized trial [41]. The second version, self-controlled desensitization, involves utilization of cognitive restructuring and relaxation skills during imagery exposure to anxiety-provoking situations. It has been incorporated into CBT in a number of studies [42]. Exposure to anxiety-provoking situations This technique involves repeated exposure to situations that are avoided or engaged in with excessive preparation or checking. Patients generate a hierarchy of situations or activities. Examples include allowing children to have sleep overs, family vacations, arriving on time (instead of excessively early) at scheduled appointments, taking on responsibilities, or saying no to requests. Patients rehearse cognitive restructuring and relaxation coping skills in session. Subsequently, they practice using these techniques to manage anxiety in situations that occur between sessions.

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Additional components Other techniques that may be incorporated into CBT for GAD include: Problem-solving to combat indecisiveness and increase the ability to generate alternative solutions to problems [43] Time management training and goal setting to facilitate present task accomplishment instead of allowing worry to dominate [44] Relapse prevention A final step in CBT is relapse prevention, in which patients are informed that recurrences of worry, anxiety or avoidance behavior are likely to occur in the future. They are encouraged to view such recurrences as lapses rather than failure, and to reapply their coping skills and reinstitute their practice of exposure to images of negative outcomes and anxiety-provoking situations. Efficacy A carefully conducted 2005 meta-analysis of 65 randomized and nonrandomized controlled trials with 7739 participants found that CBT was effective for GAD, superior to no treatment (effect size = 0.82) [45]. Other meta-analyses have identified effect sizes for CBT compared to other control conditions: waiting list and placebo controls (effect size = 1.8) [46] and placebo controls only (effect size = 0.44 to 0.57) [47]. Treatment effects from CBT have been found to persist for 6 to 12 months [45,48]. Clinical trials published since 2005 found an average response rate of 56 percent (range = 44 to 71 percent) at the end of treatment and 57 percent (range =39 to 76 percent) at 6- to 12-month follow-up [42,49-54]. These rates reflect complete samples in all but one case [52], with average attrition at 10.7 percent (range = 0 to 23 percent). CBT has been found to be more effective than nondirective supportive therapy [39,55] and more effective than psychodynamic therapy [56,57]. (See 'Psychodynamic therapy' below.) Several short-term economic analyses have found CBT to be cost effective [7]. Studies have reported reductions in patient use of medication for GAD following CBT [58,59]. Individual components It is unclear which components are critical to CBTs effectiveness. Trials have provided evidence for the effectiveness of most of the components as stand-alone treatments. Trials comparing individual components have had mixed results. As examples: Two randomized trials and a meta-analysis suggest applied relaxation may be effective as a stand-alone treatment for GAD [41,49,60]. Cognitive therapy has been shown to be an effective stand-alone treatment for GAD [39,58,61,62]. Computerized training programs for modifying attentional bias have been shown to significantly improve GAD symptoms in several studies [63]. However, they have not yet been compared to standard CBT for GAD, and the effect sizes are smaller than for CBT [64]. Self-controlled desensitization has been shown to be as effective as a stand-alone treatment in one study [62]. One trial found cognitive therapy to be superior to applied relaxation [39], but other trials found cognitive therapy and applied relaxation to be equally effective [49,58,61]. One trial found that multicomponent treatment was more effective than individual CBT components [65], whereas another trial found the two comparable [62]. Children and adolescents Two clinical trials have found CBT to be effective for anxiety disorders in children and adolescents: A clinical trial of a CBT, the Coping Cat Program, randomly assigned 47 children (9 to 13 years) with GAD, separation anxiety disorder, or social anxiety disorder to either CBT or waitlist control. After 16 sessions (four months of treatment), 64 percent no longer met diagnostic criteria for the anxiety disorder compared to 5 percent in the waitlist control group [66], with results generally maintained in patients reassessed at

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12-month and 3-year follow ups [67]. Results were replicated in a second randomized trial with 94 youths [68]. A clinical trial in children with anxiety disorders found particularly high response rates for the combination of CBT and a family-based treatment. Seventy-nine children aged 7 to 14 with separation anxiety, overanxious disorder, or social phobia were randomly assigned to CBT, CBT plus family treatment, or waiting list status with response rates of 95.6 percent for combined CBT and family treatment, 69.8 percent for CBT alone, and 26.0 percent for the waiting list group [69]. In another study, family involvement was most beneficial when both parents had an anxiety disorder [70]. Older adults Rates of response of GAD to CBT are generally lower in late-life samples compared to younger adults [52,54,71]. As an example, in a late-life sample with GAD treated with CBT in primary care, only 40 percent of the intent-to-treat sample was classified as responders [52] compared to an average 56 percent response rate found in trials of non-late-life samples. (See 'Efficacy' above.) Group treatment that encourages interaction and opportunities for self-disclosure may increase the efficacy of CBT in older adults [72]. Additional treatment considerations include learning aids (eg, acronyms for techniques) and memory enhancers (eg, homework reminders, weekly reviews of techniques) to compensate for reduced shortand long-term memory abilities, fewer homework assignments, and a slower pace of CBT sessions. Computer-based CBT Two randomized trials have found internet-based delivery of CBT with therapist support to be effective for GAD compared to waiting list controls, with effect sizes of 1.08 and 1.13. Acceptability and completion rates were high [73]. In children (aged 7 to 13 years), computer-assisted CBT that involved the therapist did not differ from fully therapist-delivered CBT at either post or three-month follow-up in terms of symptom outcomes or treatment satisfaction, with both conditions more effective than computer-assisted education, support, and attention [74]. In adults with mixed anxiety disorders in primary care settings, a treatment arm that was comprised largely of computer-assisted CBT delivered by a clinician combined with psychotropic medication optimization was found to be more effective than treatment as usual for patients with GAD [75]. Predictors of better outcome CBT generally appears to have comparable effectiveness in GAD across gender and socioeconomic status [51]. Interpersonal difficulties have been found to predict poorer outcomes from CBT for GAD [62,76], as have poor physical health and high baseline levels of neuroticism for those with late-life anxiety including GAD [51]. Individuals with GAD have high rates of co-occurring psychiatric disorders [77,78]; however, studies of the influence of comorbidity on the outcome of CBT for GAD are mixed. Some studies find that baseline comorbidity is associated with a worsened outcome [76], although a number of studies show either no effect or improved outcomes in GAD with a co-occurring disorder [54,79,80]. Research has found CBT for GAD to result in improvements in co-occurring anxiety disorders and depression [80,81]. (See "Generalized anxiety disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".) Frequency and duration of treatment CBT is generally provided in 10 to 15 60-minute sessions for GAD, but can include additional sessions depending on patients level of severity, the presence of comorbidity, patient resistance to the treatment approach, therapist competence, and the number of components incorporated into CBT. CBT treatment sessions are always accompanied by homework assignments, usually daily, to be conducted between sessions. Thus, therapy time for the patient is more extensive than the time spent in-session with therapists. COMBINED CBT AND MEDICATIONS Evidence from clinical trials suggests that the combination of CBT and either benzodiazepines [82,83] or sertraline [84] is more effective in GAD than the medications alone. (See "Pharmacotherapy for generalized anxiety disorder", section on 'Combined medication and CBT'.) COMPARING CBT TO MEDICATION There is insufficient evidence comparing CBT to medication for GAD to favor one modality over the other. Selection between these modalities may be based on treatment availability and patient preference. (See "Pharmacotherapy for generalized anxiety disorder", section on 'Comparing medication to CBT'.)

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OTHER PSYCHOTHERAPIES Although nearly all clinical trials of psychotherapy effective in GAD focus on CBT, other psychotherapies have been studied for the disorder. Psychodynamic therapy In psychodynamic approaches to GAD, treatment typically focuses upon core conflictual relationship themes. Emphasis is placed upon a positive therapeutic alliance to provide a corrective emotional experience to offset insecure attachment. Findings from a small clinical trial provide some evidence of effectiveness for supportive-expressive therapy, a short-term psychodynamic therapy, in GAD [85]. Thirty-one patients with GAD randomly assigned either to supportive-expressive therapy or supportive therapy showed no difference in mean GAD symptom reduction, but supportive-expressive therapy led to a higher rate of remission. Two clinical trials have found CBT to be more effective than psychodynamic therapy in GAD: In one trial, 110 patients with GAD were randomly assigned to CBT, psychodynamic therapy, or anxiety management training [56]. Patients in all three groups showed improvement; however, patients receiving CBT showed greater improvement than patients receiving psychodynamic therapy. This study was limited in that the delivery of CBT was supported by therapist training, an instructive manual, and fidelity assessment, while psychodynamic therapy was not [57]. A clinical trial comparing supportive-expressive therapy, a short-term psychodynamic therapy, and CBT in 57 patients with GAD was designed to address limitations of the previous trial [57]. Both therapies led to large reductions in GAD symptoms, with no difference seen between the two groups in the primary outcome, the Hamilton Anxiety Rating Scale. However, CBT showed superior results on self-report measures of trait anxiety and worry [57]. Emotional regulation therapy Emotional regulation therapy incorporates components of CBT such as psychoeducation and self-monitoring, as well as interventions that address emotion regulation (deficits prominent in GAD), emotional avoidance, and interpersonal difficulties [86]. A clinical trial comparing CBT plus emotion-focused and interpersonal strategies with CBT plus supportive listening in 83 patients with GAD found both groups to experience reduced GAD symptoms, with no differences seen between groups [42]. Acceptance and commitment therapy Mindfulness-based (ie, nonjudgmental observation of moment to moment experiences) psychotherapies have been shown to be efficacious in decreasing anxiety symptoms in an uncontrolled study of individuals with GAD and panic disorder [87]. Acceptance and Commitment Therapy (ACT) [88] combines mindfulness with acceptance of internal states and orientation of actions towards valued goals. Although there are some similarities between an ACT approach and a CBT approach [89], ACT does not involve any form of cognitive restructuring (ie, identifying, challenging, and replacing negative thinking with more realistic thinking) or any attempt to change or correct somatic dysregulation (eg, relaxation training). A preliminary randomized trial of 16 patients supports the efficacy of an ACT approach for GAD [90]. SUMMARY AND RECOMMENDATIONS We recommend that patients with generalized anxiety disorder (GAD) be treated with cognitive behavioral therapy (CBT), a serotonergic antidepressant, or both, rather than no treatment (Grade 1A). No difference in efficacy has been found between CBT and serotonergic antidepressants; selection between them can be made on the basis of patient preference and treatment availability. (See "Pharmacotherapy for generalized anxiety disorder", section on 'Comparing medication to CBT' and 'Comparing CBT to medication' above.) We suggest treatment of GAD with CBT rather than nondirective supportive therapy or psychodynamic therapy (Grade 2B) or other psychotherapies. (See 'Efficacy' above and 'Other psychotherapies' above.) The theoretical foundation of CBT for GAD derives from research on cognitive, physiological, and behavioral features of persons with the disorder. (See 'Theoretical foundation' above.) CBT is a multimodal intervention. Specific techniques used in the therapy include education, self-monitoring, relaxation training, cognitive restructuring, exposure to imagery and anxiety-producing situations, and relapse prevention. (See 'Specific techniques' above.)

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CBT is generally provided in 10 to 15 60-minute sessions for GAD, but can include additional sessions depending on patients level of severity, the presence of comorbidity, patient resistance to the treatment approach, therapist competence, and the number of components incorporated into CBT. (See 'Frequency and duration of treatment' above.) Use of UpToDate is subject to the Subscription and License Agreement. Topic 14632 Version 3.0

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GRAPHICS Worry record

From: Craske MG, Barlow DH. Mastery of Your Anxiety and Worry, 2nd, Oxford University Press, New York 2006. p.17. By permission from Oxford University Press, Inc. (www.oup.com).

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