Metacognitive therapy versus cognitive-behavioural therapy in adults with generalised anxiety disorder.

BACKGROUND: Cognitive-behavioural therapy (CBT) is the treatment of choice for generalised anxiety disorder (GAD), yielding significant improvements in approximately 50% of patients. There is significant room for improvement in the outcomes of treatment, especially in recovery. AIMS: We aimed to compare metacognitive therapy (MCT) with the gold standard treatment, CBT, in patients with GAD (clinicaltrials.gov identifier: NCT00426426). METHOD: A total of 246 patients with long-term GAD were assessed and 81 were randomised into three conditions: CBT (n = 28), MCT (n = 32) and a wait-list control (n = 21). Assessments were made at pre-treatment, post-treatment and at 2 year follow-up. RESULTS: Both CBT and MCT were effective treatments, but MCT was more effective (mean difference 9.762, 95% CI 2.679-16.845, P = 0.004) and led to significantly higher recovery rates (65% v. 38%). These differences were maintained at 2 year follow-up. CONCLUSIONS: MCT seems to produce recovery rates that exceed those of CBT. These results demonstrate that the effects of treatment cannot be attributed to non-specific therapy factors. DECLARATION OF INTEREST: A.W. wrote the treatment protocol in MCT and several books on CBT and MCT, and receives royalties from these. T.D.B. wrote the protocol in CBT and has published several articles and chapters on CBT and receives royalties from these. All other authors declare no competing interests.

The Effects of Worry and Relaxation on Flexibility During Cognitive Restructuring.

Worry is associated with inflexibility in cognitive, emotional, and physiological functioning. In addition, worry's negative valence and abstract level of construal are rigid characteristics that contribute to its nonadaptive consequences. Relaxation and cognitive therapy aim to increase flexibility in chronic worriers, and may have greater efficacy when administered in combination. We examined the extent to which relaxation enhances and/or worry inhibits cognitive flexibility during a cognitive restructuring exercise in which participants generated alternative predictions for their worries. Participants ( n = 189) were randomly assigned to engage in relaxation, worry, or neutral thinking prior to cognitive restructuring. We measured the number and perceived likelihood of alternative predictions generated by participants, and coded those alternative predictions for their degree of positive valence, negative valence, and level of construal (abstractness to concreteness). Worry and relaxation did not lead to different numbers or perceived likelihood of alternative predictions. However, compared with participants with minimal symptoms of generalized anxiety disorder (GAD), those with elevated symptoms of GAD who engaged in prior worry generated alternative predictions characterized by greater negative valence and more abstractness (i.e., less concreteness). We also found that greater negative valence of alternative predictions was associated with more abstractness, whereas greater positive valence of alternative predictions was associated with more concreteness. These findings suggest that after engaging in worry, individuals with GAD may be less able to flexibly shift from the use of nonadaptive characteristics (negative valence, abstractness) associated with feared outcomes to the use of more adaptive characteristics (positive valence, concreteness) when considering alternative predictions.

A contemporary view of applied relaxation for generalized anxiety disorder.

Applied relaxation (AR), originally developed by Lars-Göran Öst, is a long-standing, efficacious treatment for generalized anxiety disorder (GAD). While newer treatments are continuing to be developed, AR remains one of the most efficacious treatments for GAD. However, AR has received less in-depth attention more recently, particularly in terms of potential mechanisms of action. This article is written to honor the development and history of AR and to highlight the ways that it has continued to be adapted. In this article, AR treatment strategies are presented, which include: noticing early signs of anxiety, learning relaxation skills, and applying relaxation at the first sign of anxiety. Then, additional adaptations to AR are presented along with recommendations of how AR may be enhanced by understanding potential mechanisms of change. Finally, recommendations are made for the continued evolution of AR as a powerful and efficacious treatment for GAD.

A randomized controlled trial of cognitive-behavioral therapy for generalized anxiety disorder with integrated techniques from emotion-focused and interpersonal therapies.

OBJECTIVE: Recent models suggest that generalized anxiety disorder (GAD) symptoms may be maintained by emotional processing avoidance and interpersonal problems. METHOD: This is the first randomized controlled trial to test directly whether cognitive-behavioral therapy (CBT) could be augmented with the addition of a module targeting interpersonal problems and emotional processing. Eighty-three primarily White participants (mean age = 37) with a principle diagnosis of GAD were recruited from the community. Participants were assigned randomly to CBT plus supportive listening (n = 40) or to CBT plus interpersonal and emotional processing therapy (n = 43) within a study using an additive design. Doctoral-level psychologists with full-time private practices treated participants in an outpatient clinic. Using blind assessors, participants were assessed at pretreatment, posttreatment, 6-month, 1-year, and 2-year follow-up with a composite of self-report and assessor-rated GAD symptom measures (the Penn State Worry Questionnaire; T. J. Meyer, M. L. Miller, R. L. Metzger, & T. D. Borkovec, 1990; Hamilton Anxiety Rating Scale; M. Hamilton, 1959; assessor severity rating; State-Trait Anxiety Inventory-Trait Version; C. D. Spielberger, R. L. Gorsuch, R. Lushene, P. R. Vagg, & G. A. Jacobs, 1983) as well as with indices of clinically significant change. RESULTS: Mixed models analysis of all randomized participants showed very large within-treatment effect sizes for both treatments (CI = [-.40, -.28], d = 1.86) with no significant differences at post (CI = [-.09, .07], d = .07) or 2-year follow-up (CI = [-.01, .01]), d = .12). There was also no statistical difference between compared treatments on clinically significant change based on chi-square analysis. CONCLUSIONS: Interpersonal and emotional processing techniques may not augment CBT for all GAD participants. Trial Registry name: Clinical Trials.gov, Identifier: NCT00951652.

Diagnostic comorbidity in adults with generalized anxiety disorder: impact of comorbidity on psychotherapy outcome and impact of psychotherapy on comorbid diagnoses.

The current study examined the impact of comorbidity on cognitive and behavioral therapies for generalized anxiety disorder (GAD) as well as the impact of these therapies on diagnoses comorbid to GAD. Seventy-six treatment-seeking adults with principal diagnoses of GAD received 14 sessions of therapy. Most (n=46; 60.5%) of the sample had at least one comorbid diagnosis. Although the presence of comorbid diagnoses was associated with greater severity of GAD symptoms at pretreatment, greater severity of comorbid major depression, simple phobia, and social phobia was associated with greater change in symptoms of GAD in response to treatment, with no effect on maintenance of gains during a 2-year follow-up. Further, psychotherapy for principal GAD led to a reduction in number of comorbid diagnoses and in severity of social phobia, simple phobia, and major depression at posttreatment. At 2-year follow-up severity of social and simple phobia remained below pretreatment levels, whereas severity of depression was no longer significantly below pretreatment levels. These results suggest that although people with comorbid disorders enter treatment with more severe GAD symptomatology, they demonstrate greater change, and therefore such comorbidity does not diminish the efficacy of cognitive and behavioral therapies for GAD. In addition, the impact of these treatments for GAD may generalize to reduced severity of simple phobia, social phobia, and major depression; however, gains in severity of major depression are not maintained.

Generalized worry disorder: a review of DSM-IV generalized anxiety disorder and options for DSM-V.

BACKGROUND: Generalized anxiety disorder (GAD) has undergone a series of substantial classificatory changes since its first inclusion in DSM-III. The majority of these revisions have been in response to its poor inter-rater reliability and concerns that it may lack diagnostic validity. This article provides options for the revision of the DSM-IV GAD criteria for DSM-V. METHOD: First, searches were conducted to identify the evidence that previous DSM Work Groups relied upon when revising the DSM-III-R GAD and the overanxious disorder classifications. Second, the literature pertaining to the DSM-IV criteria for GAD was examined. CONCLUSIONS: The review presents a number of options to be considered for DSM-V. One option is for GAD to be re-labeled in DSM-V as generalized worry disorder. This would reflect its hallmark feature. Proposed revisions would result in a disorder that is characterized by excessive anxiety and worry generalized to a number of events or activities for 3 months or more. Worry acts as a cognitive coping strategy that manifests in avoidant behaviors. The reliability and validity of the proposed changes could be investigated in DSM-V validity tests and field trials.

Future-oriented decision-making in Generalized Anxiety Disorder is evident across different versions of the Iowa Gambling Task.

Generalized Anxiety Disorder (GAD) and excessive worrying are characterized by a preoccupation with the future. Thus, enhanced identification of potential future punishments or omissions of reward may be related to the disorder. To test this hypothesis, n=47 students meeting GAD criteria according to the GADQ-IV (GAD analogues) or not (control participants) performed the Iowa Gambling Task, which has been related to sensitivity to future consequences. In order to disentangle sensitivity to future loss and sensitivity to high short-term loss magnitudes, which could also lead to enhanced Iowa Gambling Task performance, participants also performed a modified version of the task with reversed contingencies. In both versions, GAD analogues learned to avoid decisions with high probability of long-term loss significantly faster than control participants. Results, therefore, indicate that GAD is characterized by enhanced processing of potential future losses rather than sensitivity to large short-term loss.

Helpful and hindering events in psychotherapy: a practice research network study.

This paper presents the findings of a psychotherapy process study conducted within the Pennsylvania Psychological Association Practice Research Network (PPA-PRN). The investigation was the product of a long-term collaborative effort, both in terms of the study design and implementation, between experienced clinicians of various theoretical orientations and full-time psychotherapy researchers. Based on a relatively large sample of clients seen in independent practice settings, close to 1,500 therapeutic events (described by clients and therapists as being particularly helpful or hindering) were collected. These events were coded by three independent observers using a therapy content analysis system. Among the findings, both clients and therapists perceived the fostering of self-awareness as being particularly helpful. The results also point to the importance of paying careful attention to the therapeutic alliance and other significant interpersonal relationships. The merits and difficulties of conducting scientifically rigorous and clinically relevant studies in naturalistic contexts are also discussed.

Psychotherapists, researchers, or both? A qualitative analysis of psychotherapists' experiences in a practice research network.

This paper describes the experiences of psychotherapists who, as part of a practice research network (PRN), collaborated with researchers in designing and conducting a psychotherapy study within their own clinical practices. A qualitative analysis of interviews conducted with these psychotherapists led to the delineation of several benefits (e.g., learning information that improved their work with clients and feeling that they were contributing to research that would be useful for psychotherapists) and difficulties for them and their clients (e.g., time and effort required to integrate research protocol into routine clinical practice) that psychotherapists associated with their participation in the PRN. Also identified were a number of strategies used by psychotherapists to address obstacles that they encountered, as well as general recommendations for future PRN studies. As a whole, the experiences of these psychotherapists are likely to provide valuable lessons for the survival and growth of what is viewed by many as a promising pathway for building a stronger bridge between practice and research.

Generalized anxiety disorder: connections with self-reported attachment.

Even though generalized anxiety disorder (GAD) is one of the most common of the anxiety disorders, relatively little is known about its precursors. Bowlby's attachment theory provides a framework within which these precursors can be considered. According to Bowlby, adult anxiety may be rooted in childhood experiences that leave a child uncertain of the availability of a protective figure in times of trouble.Furthermore, adult "current state of mind with respect to attachment" is thought to relate to adult anxiety. Both attachment-related components were assessed with 8 subscales of the Perceptions of Adult Attachment Questionnaire(PAAQ). Clinically severe GAD clients who were about to begin therapy reported experiencing less maternal love in childhood, greater maternal rejection/neglect, and more maternal role-reversal/enmeshment than did control participants.In keeping with a cumulative risk model, risk for GAD increased as indices of poor childhood attachment experience increased. GAD clients, in contrast to controls,also reported greater current vulnerability in relation to their mothers as well as more difficulty accessing childhood memories. Logistic regression analyses revealed that elevations on PAAQ subscales could significantly predict GAD vs.non-GAD status. Results and the implications for advancing the theory and treatment of GAD are discussed.

Startle response in generalized anxiety disorder.

BACKGROUND: The main purpose of the present study was to examine the startle reflex in individuals diagnosed with Generalized Anxiety Disorder (GAD) and control participants in terms of three questions. First, is the basic startle reflex modulated by autonomic nervous system (ANS) activation and/or attentional focus? Second, are induced and self-reported emotional states related to the magnitude of the startle response? And third, do individuals with GAD and their controls show differential startle responses? METHODS: Experimental tasks designed to elicit sympathetic and parasympathetic activation and requiring internal and external attention foci were administered to nine individuals with GAP and nine controls. RESULTS: Individuals with GAD showed a greater startle reflex than controls during involvement in tasks that either induced worry or relaxation but not during a baseline period. Startle responses differed in terms of intentional focus but not ANS activity. During baseline and emotional induction, self-reported negative emotionality was significantly correlated with magnitude of the startle response. CONCLUSIONS: These results suggest that negative emotionality at the time of the startle probe is an important determinant. Further, attentional focus plays a more important role in startle modulation than autonomic nervous system manipulation. These results are discussed in relation to negative emotion, focus of attention, and use of the startle response as a measure of change during psychotherapy.

Worry, generalized anxiety disorder, and emotion: evidence from the EEG gamma band.

The present study examined EEG gamma (35-70 Hz) spectral power distributions during worry inductions in participants suffering from generalized anxiety disorder (GAD) and in control participants without a history of psychiatric illness. As hypothesized, the EEG gamma band was useful for differentiating worry from baseline and relaxation. During worry induction, GAD patients showed higher levels of gamma activity than control participants in posterior electrode sites that have been previously associated with negative emotion. Gamma fluctuations in these electrode sites were correlated with subjective emotional experience ratings lending additional support to interpretations of negative affect. Following 14 weeks of psychotherapy, the GAD group reported less negative affect with worry inductions and the corresponding gamma sites that previously differentiated the clinical from control groups changed for the GAD patients in the direction of control participants. These findings suggest converging evidence that patients suffering from GAD experience more negative emotion during worry and that the EEG gamma band is useful for monitoring fluctuations in pathological worry expected to follow successful treatment.

AN OPEN TRIAL OF INTEGRATIVE THERAPY FOR GENERALIZED ANXIETY DISORDER.

Cognitive- behavioral therapy (CBT), although effective, has the lowest average effect size for generalized anxiety disorder (GAD), when compared to effect sizes of CBT for other anxiety disorders. Additional basic and applied research suggests that although interpersonal processes and emotional avoidance may be maintaining GAD symptomatology, CBT has not sufficiently addressed interpersonal issues or emotion avoidance. This study aimed to test the feasibility and preliminary efficacy of an integrative psychotherapy, combining CBT with techniques to address interpersonal problems and emotional avoidance. Eighteen participants received 14 sessions of CBT plus interpersonal emotional processing therapy and three participants (for training and feasibility purposes) received 14 sessions of CBT plus supportive listening. Results showed that the integrative therapy significantly decreased GAD symptomatology, with maintenance of gains up to 1 year following treatment. In addition, comparisons with extant literature suggested that the effect size for this new GAD treatment was higher than the average effect size of CBT for GAD. Results also showed clinically significant change in GAD symptomatology and interpersonal problems with continued gains during the 1-year follow-up. Implications of these results are discussed.

The effects of worry and rumination on affect states and cognitive activity.

The effects of worry and rumination on affective states and mentation type were examined in an unselected undergraduate sample in Study 1 and in a sample of individuals with high trait worry and rumination, high rumination, and low worry/rumination in Study 2. Participants engaged in worry and rumination inductions, counterbalanced in order across participants to assess main and interactive effects of these types of negative thinking. During mentation periods, the thought vs. imaginal nature and the temporal orientation of mentations were assessed 5 times. Following mentation periods, negative and positive affect, relaxation, anxiety, and depression were assessed. Both worry and rumination produced increases in negative affect and decreases in positive affect. Worry tended to generate greater anxiety, and rumination tended to generate greater depression. Interactive effects were also found indicating that worry may lessen the anxiety experienced during subsequent rumination. Moreover, worry lessened the depressing effects of rumination. Worry was associated with significantly greater thought than imagery, compared to rumination. Rumination involved a progression from mentation about the past to mentation about the future over time. Implications for understanding the generation of negative affect and comorbid anxiety and depression are discussed.

Interpersonal process and outcome in variants of cognitive-behavioral psychotherapy.

Early sessions from three variants of cognitive-behavioral therapy (CBT) were examined to replicate work done in psychodynamic-interpersonal treatments linking interpersonal process to outcome (W. P. Henry, T. E. Schacht, & H. H. Strupp, 1986, 1990). Cases were available from a component study of CBT for generalized anxiety disorder (T. D. Borkovec, M. G. Newman, A. L. Pincus, & R. Lytle, 2002) and were selected to form good and poor outcome groups maintained through a 1-year follow-up. A third group was also examined that had initial positive outcomes and marked decline by follow-up (n = 8 for each). Structural analysis of social behavior (SASB) was used to identify interpersonal behaviors. Contrary to the authors' expectation, SASB variables were not strong predictors of outcome, and lower levels of interpersonal hostility were found than was the case in previous work. Findings are discussed in light of differences observed between treatment variants and the role that manuals may have in standardizing some aspects of the therapeutic relationship.

Validity of the inventory of interpersonal problems for predicting treatment outcome: an investigation with the Pennsylvania Practice Research Network.

In this study, we examined the relationship between treatment outcome and variables from the Inventory of Interpersonal Problems Circumplex scales (IIP-C; Horowitz, Alden, Wiggins, & Pincus, 2000) in the Pennsylvania Psychological Association's Practice Research Network (PRN; Borkovec, Echemendia, Ragusea, & Ruiz, 2001). The PRN was a naturalistic observation treatment outcome study conducted with clinicians who were providing outpatient therapy. Assessment instruments, including the Compass Assessment System (Howard, Brill, Lueger, O'Mahoney, & Grissom, 1993; Sperry, Brill, Howard, & Grissom, 1996) and the IIP-C, were used to assess outcome at the 7th session (N=73) and at termination (N=42). Significant associations were identified between seventh-session outcome and most of the IIP variables. Only IIP elevation and amplitude were related to termination outcome. Elevation, amplitude, and hostile submissive problems were related to treatment length. Ad hoc analyses indicated that the IIP elevation fully mediated the relationships between interpersonal problems and seventh-session outcome but not the relationship between amplitude and outcome. We discuss the results in relation to the external validity of the IIP.

A test of the role of metaworry in the prediction of worry severity in an elderly sample.

Wells (Behav. Cogn. Psychother. 23 (1995) 301) proposed a cognitive model, which distinguishes between two kinds of worry: type I worry (focused on external things) and type II worry or metaworry (worry about one's own thoughts and worry). Wells' model assigns a central role to metaworry in the development of excessive worry, and Wells and Carter (Behav. Res. Ther. 37 (1999) 585) found in a college sample that metaworry predicted the level of trait worry after controlling for trait anxiety and type I worry. The present study replicated their investigation with a Spanish elderly sample and supported Wells' predictions that metaworry plays a significant role in the prediction of trait worry in contrast to type I worries, even when trait anxiety or perceived uncontrollability over worry are controlled.

Cognitive-behavioral therapy for generalized anxiety disorder with integrations from interpersonal and experiential therapies.

After providing background information on the definition and nature of generalized anxiety disorder, this article describes cognitive-behavioral therapy (CBT) methods that have been empirically supported in the treatment of this disorder. Subsequent to this description, relevant outcome literature is briefly reviewed, along with evidence that the addition of other techniques beyond traditional CBT methods may be necessary to maximize clinical outcome. A description is then provided of an integrated interpersonal/emotional processing therapy that the authors have recently added to their CBT protocol. CBT with and without this integrated treatment is currently being evaluated in an experimental trial.