CBT For GAD

Cognitive Behavioral Treatment of Generalized Anxiety Disorder

The original version of these slides was provided by

Michael W. Otto, Ph.D. with support from NIMH Excellence in Training Award at the Center for Anxiety and Related Disorders at Boston University (R25 MH08478)
Use of this Slide Set

Presentation information is listed in the notes section below the slide (in PowerPoint normal viewing mode). A bibliography for this slide set is provided below in the note section for this slide. References are also provided in note sections for select subsequent slides.
Slide Set Outline

Treatment outcome findings Perspectives across meta analyses
Treatment models
Similarities (over differences) Elements of treatment What is accomplished in session Future directions
Generalized Anxiety Disorder: Diagnostic Considerations

Pervasive worry and chronic arousal Residual category of panic disorder in DSM-III Spheres of worry in DSM-III-R and chronic arousal Excessive and uncontrollable worry and 3 of 6 symptoms in DSM-IV restless, keyed up, on edge easily fatigued difficulties concentrating irritability muscle tension sleep disturbance
Core Patterns in GAD

Uncontrollable worry
Future orientation
Negative cognitive biases Somatic arousal Role and task inefficiency Interpersonal aversiveness (unbalanced relationships)
GAD: Core Treatment Elements

Information Applied Relaxation Cognitive Restructuring (probability estimates, coping estimates) Cue-Controlled Worry (worry times + problem solving) Worry Exposure (including existential topics) Mindfulness
Meta-Analyses: 5 Perspectives
All Randomized Trials (pre-post) Norton & Price, 2007
Placebo-Controlled Trials (controlled effect size)

Hofmann & Smits, 2008 Elements of Treatment (controlled effect size)
Gould et al., 2004

Differential Efficacy (pre-post) Siev & Chambless, 2007
Gould et al., 2004

Effectiveness Trials (pre-post) Stewart & Chambless, 2009
Meta-Analysis of Randomized Anxiety Trials of CBT (within ES)

Norton & Price, 2007, JNMD
Effect Size (d)
Hofmann & Smits (2008) Meta-Analysis

Meta-analysis of well-controlled trials of CBT for anxiety Inclusion criteria: Random assignment to either CBT or placebo The psychological placebo had to involve interventions to control for nonspecific factors (e.g., regular contact with a therapist, reasonable rationale for the intervention, discussions of the psychological problem)
Meta-Analysis of Controlled Trials of CBT (Between ES)

Hofmann & Smits, 2008, J Clin Psychiatry
Effect Size (g)
Gould et al., 2004 Meta-Analysis

16 studies
Mean drop-out rate 11.4% Mean 10.1 hours of treatment No difference in outcome for studies allowing stabilized medications Maintenance of treatment gains across 6 months
Meta-Analysis of CBT Gould et al., 2004 Between Groups

Effect Size (d)
Specificity of Treatment
(Siev & Chambless, 2007, JCCP)
GAD
CT = RT
Panic Disorder
CT* > RT
Cognitive Therapy (CT) includes interoceptive exposure Relaxation Therapy (RT)
Meta-Analyses of Effectiveness Studies

(Within ES)
3
(Stewart & Chambless, 2009, JCCP)
Effect Size (d)
2.5
2 1.5 1 0.5 0 PTSD OCD SAD Panic GAD Agor
Comorbidity and Treatment

(Newman et al., 2010)
76 treatment seeking adults with GAD 14 sessions of treatment 60.5% had comorbidity Comorbid diagnosis linked to greater GAD severity at pretreatment
Greater change with treatment for those with comorbid depression, social anxiety disorder, specific phobia
Normal maintenance of treatment gains
Benefits to social anxiety disorder and specific phobia were maintained over 2 years, whereas benefits to depression were not
CBT Models of GAD
(Behar et al., 2009, J Anx Dis)
Avoidance Model of Worry and GAD

(Borkovec, 1994; Borkovec et al., 2004)
Intolerance of Uncertainty Model

(Dugas et al., 1995; Freeston et al., 1994)
Metacognitive Model
(Wells, 1995)
Emotion Dysregulation Model

(Mennin et al., 2002)
Acceptance-Based Model of Generalized Anxiety Disorder

(Roemer & Orsillo, 2002, 2005)
Wells (1999)
Worry is a chain of catastrophising thoughts that are predominantly verbal. It consists of the contemplation of potentially dangerous situations and of personal coping strategies. It is intrusive and controllable although it is often experienced as uncontrollable. Worrying is associated with a motivation to prevent or avoid potential danger. Worry itself may be viewed as a coping strategy but can become the focus of concern.
Two Types of Worry (Dugas & Ladouceur, 2000)

Situations amenable to problem solving Training in step-by-step problem solving
Situations that are not amenable to problem solving (hypothetical problems that never happen)
Worry times
Worry exposure
Avoidance Function of Worry

Worry, a verbal process, inhibits vivid mental imagery and associated anxiety (Borkovec) Evidence that it does attenuate: somatic arousal at rest (Hoehn-Saric & McLeod, 1988; HoehnSaric, McLeod, & Zimmerli, 1989; Lyonfields, Borkovec, & Thayer, 1995; Thayer, Friedman, &Borkovec, 1996)
upon subsequent exposure to threat-related material (Borkovec & Hu, 1990; Peasley-Miklus & Vrana, 2000)
Worry and Conditioning

Non-clinical levels of worry are linked to greater conditionability (Otto et al., 2008; Hermans et al., 2009) Potential role for rumination in keeping
CS UCS link alive
Borkovec
Encourage a present focus vs. future (past) Leave patients expectancy free
Positive Beliefs About Worries

Worrying: Is useful for finding solutions to problems
Is motivating helps get things done

Is protective from negative emotions Can prevent negative outcomes Is a positive personality trait
(Francis & Dugas, 2004)
Negative Problem Orientation

Problems are threat to well-being Doubt about problem-solving ability
Pessimism about problem solving outcome

Negative problem orientation is more specific to worry than depression in student samples, and is differentiated from neuroticism
(Robichaud & Dugas, 2005, BRAT)
Intolerance of Uncertainty
Motivates unnecessary worry-based planning
What if X happens, could I cope by
All current models tend to underscore avoidance of internal experiences

Cognitive avoidance Emotional avoidance Intolerance of uncertainty Negative cognitive reactions to emotions Combined With Positive beliefs about worry While being concerned about effects of worry
Treatment Elements
Borkovec 1. Awareness and self-monitoring 2. Relaxation
3. Cognitive therapy
4. Imagery rehearsal of coping strategies
(see Borkovec, 2006 for review)
Treatment Elements
Wells 1. Case formulation 2. Socialization to treatment
3. Modifying negative beliefs about the uncontrollability of worry

4. Modifying beliefs about the danger of worry
5. Modifying positive beliefs about worry

(Wells, 1999)
Treatment Elements
Dugas et al. 1. Uncertainty recognition and behavioral exposure 2. Re-evaluation of the usefulness of worry
3. Problem-solving training
4. Imaginal exposure (Dugas et al., 2003)
Relaxation Strategies
Progressive Relaxation (PR; e.g., Bernstein & Borkovec, 1973) Applied Relaxation (AR;O st, 1987). AR does include exposure elements
Mechanism of Relaxation Training

(Ost, 1992) Reduces general tension and anxiety (and link stressor/panic) Enhances awareness about how anxiety works, demystifying and diminishing its impact Enhances self-efficacy : individuals feel equipped to cope with anxiety
Relaxation Training
Feel the difference between tension and relaxation Tense 7 seconds, relax 15
Specific muscle groups to learn the procedure

Group them as skill increases Use 10-second relaxation cue
The Words of Worry

Non-specific and hard to dispute It will be horrible
It will be a disaster
Downward Arrow Techniques to clarify worries and put them in a form appropriate for cognitiverestructuring
Cognitive Restructuring
Self monitoring Logical analysis
Probability overestimations
Overestimations of the degree of catastrophe Ability to cope
Relapse Prevention in Depression Metacognitive Awareness

Classic CT and mindfulness-based CT both enhance metacognitive awareness Level of metacognitive awareness is linked to relapse Changing the relationship people have to their thoughts, rather than changing beliefs, may be important for preventing relapse
(Teasdale et al., 2002)
Mindfulness
Curious attention to the present moment, in an open, nonjudgmental, and accepting manner
(Bishop et al., 2004; Germer, 2005; Kabat-Zinn, 1994)
Why Mindfulness?
Hayes and Feldman, 2004
Mindfulness training may enhance emotional regulation by addressing the patterns of over-engagement (e.g., rumination) and under-engagement (avoidance) that characterizes the disorder. Target is a healthy level of engagement that allows clarity and functional use of emotional responses
Roemer et al, 2009

Non-clinical symptoms and clinical GAD status linked to lower mindfulness
Worry Time
Save up the worry (cue specificity) End of the day worry time
In office (non-fun) setting

45 min with writing 10 min relaxation skills Go have fun
GAD: Worry Exposure

Metaphor: Like watching a scary movie over and over decreased arousal and changed meaning of the worry Apply exposure plus response prevention (including the use of tape loops) The goal is elimination of the worry response via repeated exposure to core fears This technique should also be coupled with the prescription to worry through one topic and not switch among spheres of worry
GAD: Training in Normal Thinking

Teach normal thinking as alternative behavior. What does one think about when not preoccupied with worry? Mindfulness of thinking states that are different from worry (e.g. daydreaming, experiencing, planning, enjoying) Sensory awareness training Staying in the moment Use of worry times Limited effects of exposure on valence/preference
Attention ModificationTraining - GAD

29 treatment seeking patients Random assignment (train away vs. no train threat words)
8 sessions over 4 weeks

Goal: Change attentional bias
Change GAD symptoms

Succeeded with both Between group effect size of .80
Least efficacy on worry

(Amir et al., 2009, J Abn Psych)
Attention Modification Training - GAD

Randomized clinical trial GAD (N = 29)
Stimuli: threatening or neutral words 50% of those in the active attention modification program were classified as responders (no longer meeting DSM diagnosis for GAD) vs. 13% in the control condition
(Amir et al., 2009)
New Directions
Attentional training
Mindfulness/emotional tolerance training

Interoceptive exposure Integrative treatment
GAD Interpersonal Roles

Polarizing the relationship: the worry partner Improving couples problem-solving
Conclusions
Nice convergence of strategies in the field Need to convincingly beat relaxation training as a first step in care Need to confirm resilience of treatment to depression (but emergent finding across anxiety disorders) Room for improvement to achieve high end-state functioning

CBT For GAD

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Cognitive Behavioral Treatment of Generalized Anxiety Disorder

The original version of these slides was provided by

Use of this Slide Set

Slide Set Outline

Generalized Anxiety Disorder: Diagnostic Considerations

Core Patterns in GAD

GAD: Core Treatment Elements

Placebo-Controlled Trials (controlled effect size)

Gould et al., 2004

Gould et al., 2004

Meta-Analysis of Randomized Anxiety Trials of CBT (within ES)

Effect Size (d)

Hofmann & Smits (2008) Meta-Analysis

Meta-Analysis of Controlled Trials of CBT (Between ES)

Effect Size (g)

Gould et al., 2004 Meta-Analysis

Meta-Analysis of CBT Gould et al., 2004 Between Groups

Cognitive Therapy (CT) includes interoceptive exposure Relaxation Therapy (RT)

Meta-Analyses of Effectiveness Studies

(Stewart & Chambless, 2009, JCCP)

Effect Size (d)

Comorbidity and Treatment

CBT Models of GAD

(Behar et al., 2009, J Anx Dis)

Avoidance Model of Worry and GAD

Intolerance of Uncertainty Model

Emotion Dysregulation Model

Acceptance-Based Model of Generalized Anxiety Disorder

Two Types of Worry (Dugas & Ladouceur, 2000)

Avoidance Function of Worry

Worry and Conditioning

CS UCS link alive

Positive Beliefs About Worries

Is motivating helps get things done

Negative Problem Orientation

Pessimism about problem solving outcome

Motivates unnecessary worry-based planning

What if X happens, could I cope by

All current models tend to underscore avoidance of internal experiences

3. Modifying negative beliefs about the uncontrollability of worry

5. Modifying positive beliefs about worry

Mechanism of Relaxation Training

Specific muscle groups to learn the procedure

The Words of Worry

Relapse Prevention in Depression Metacognitive Awareness

Roemer et al, 2009

In office (non-fun) setting

GAD: Worry Exposure

GAD: Training in Normal Thinking

Attention ModificationTraining - GAD

8 sessions over 4 weeks

Change GAD symptoms

Least efficacy on worry

Attention Modification Training - GAD

(Amir et al., 2009)

Mindfulness/emotional tolerance training

GAD Interpersonal Roles

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