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Ariel J. Lang
Treating Generalized Anxiety Disorder
With Cognitive-Behavioral Therapy
Ariel J. Lang, Ph.D.
Cognitive-behavioral therapy (CBT) can be successfully used to treat generalized anxiety disorder
(GAD), with or without the inclusion of anxiolytics. The treatment of GAD using cognitive-behavioral
techniques involves cognitive restructuring, relaxation, worry exposure, behavior modification, and
problem solving. This article will review the principles used in CBT for the treatment of GAD and will
discuss recent modifications of CBTs and how they may be employed. The simultaneous use of CBT
and antidepressants will also be reviewed. (J Clin Psychiatry 2004;65[suppl 13]:14–19)
he chronicity and negative impact of generalized symptom management techniques, relaxation, cognitive
Tanxiety disorder (GAD) have been well established restructuring, worry exposure, behavior modification,
1
(see the article by Stein in this supplement). Among skill building, and self-monitoring. Therapists may em-
the efficacious treatment approaches for this distressing phasize the behavioral or cognitive components or present
and disabling condition is cognitive-behavioral therapy a mix of both.
(CBT). The purpose of this article is to describe the
cognitive-behavioral approach to the treatment of GAD, COMPONENTS OF CBT FOR GAD
detail some recent modifications of this approach, review
the empirical basis for the use of CBT with GAD, and dis- Psychoeducation
cuss the combination of psychopharmacologic and psy- Psychoeducation involves providing information about
chotherapeutic treatment. GAD and its treatment. This process serves several pur-
Cognitive-behavioral therapy is a psychotherapeutic poses. Psychoeducation can be very reassuring; a patient
approach designed to alter behavior and cognition that may feel better simply by knowing that others struggle
produces and maintains emotional distress. In CBT, both with controlling worry as well. It can also destigmatize the
the patient and therapist are actively involved in the pro- diagnosis because worry is viewed as an extension of nor-
cess to alter such distress. The therapist often uses the mal experience. Education enhances motivation for treat-
Socratic method to elicit relevant information from the pa- ment because patients understand why each of the compo-
tient. The therapist takes a stance of collaborative empiri- nents is used. Development of realistic expectations about
cism; the patient and therapist work together to develop treatment, including duration, frequency of meetings, and
hypotheses and test these ideas. Work done outside of the expectations about homework, may increase compliance.
therapy session (e.g., self-monitoring, behavioral experi- Presenting the patient’s role as an active one also helps to
ments, or exposure) is as important as, if not more impor- build the collaborative relationship that is a pillar of the
tant than, the work done in session. cognitive-behavioral approach.
Cognitive-behavioral therapy for GAD may include Specifically, GAD is presented as a disorder in which
any or all of the following techniques: psychoeducation, worry has become uncontrollable and interferes with day-
to-day activities and quality of life. Physical symptoms of
GAD are explained as an outgrowth of living with chronic
anxiety. The interrelationships between thoughts, behav-
iors, and emotions (often called the cognitive triangle) are
presented to help the patient understand the maintenance
From the University of California San Diego, and VA San of his or her anxiety problem and the rationale for the
Diego Healthcare System, San Diego, Calif. 2–5
This article is derived from the teleconference “New components of treatment.
Perspectives for Treating GAD,” which was held May 5, 2003,
and supported by an unrestricted educational grant from Self-Monitoring
Forest Laboratories, Inc. An honorarium for Dr. Lang’s Self-monitoring involves recording subjective anxiety
involvement in this supplement has been paid to the author’s
institution, UCSD, to support her research program. and situational information between treatment sessions.
Corresponding author and reprints: Ariel J. Lang, Ph.D., This procedure is used to gauge response to treatment, as-
University of California at San Diego, 8810 Rio San Diego Dr., sist in a functional analysis of worry and anxiety (e.g.,
San Diego, CA 92108 (e-mail: ajlang@ucsd.edu).
© COPYRIGHT 2004 PHYSICIANS POSTGRADUATE PRESS, INC. © COPYRIGHT 2004 PHYSICIANS POSTGRADUATE PRESS, INC.
14 J Clin Psychiatry 2004;65 (suppl 13)
Treating GAD With CBT
What triggers anxiety? What is the thought content during patient will be asked to practice this technique as anxious
times of high anxiety?), and aid the patient in early identi- thoughts arise between therapy sessions.
fication of the anxiety response. The process itself often
reduces anxiety. Examples of self-monitoring materials Worry Exposure
are available through a number of sources.2,3 Worry exposure involves systematic and repeated ex-
posure to catastrophic images associated with worry. This
Symptom Management Techniques technique is designed to reduce anxiety associated with
Symptom management techniques are designed to al- each of the images through repeated exposure to the same
leviate the immediate uncomfortable effects of anxiety. stimulus, which leads to decreased emotional response to
6
Such techniques are used to relieve the immediate discom- that stimulus (detailed discussion of this mechanism is
fort associated with anxiety, foster a sense of being able to described elsewhere in this supplement).
control one’s anxiety, and disrupt the information process- To accomplish worry exposure, the patient and thera-
ing biases (e.g., selective attention to threatening materials pist develop a list of worries, ordered by the level of asso-
or bias toward anxious interpretations of ambiguous mate- ciated anxiety. Generally, exposure will proceed from less
rials) that accompany anxiety. to more anxiety-provoking worries. For each scenario, the
Relaxation strategies are the most common symptom patient is asked to vividly conjure the image and remain
management techniques. Progressive muscle relaxation focused on it for 25 to 30 minutes. Following this image
(i.e., systematically tensing and then relaxing muscle technique the patient is asked to generate other possible
groups) is probably the most commonly used technique outcomes for the same situation.
for GAD, but there is a wide range of effective ap-
proaches, including deep breathing and meditation tech- Other Techniques
niques. Many therapists find it useful to present a number The purpose of behavioral modification is to alter
of such strategies and allow the patient to select those that behaviors that contribute to anxiety. One example is re-
he or she prefers. Distraction is another technique that can ducing negatively reinforcing behaviors (i.e., behaviors
be applied in the short term. For example, a patient may be that are reinforcing because they increase anxiety), such as
taught to focus carefully on what other people are saying checking or other “compulsive” behaviors, or avoidance.
in social settings as a way to distract himself or herself The therapist may also suggest that the patient schedule
from feeling anxious. It should be made clear, however, “worry time.” This technique is used to reduce the total
that distraction is not a good long-term strategy because it amount of worry time by concentrating worry in a single
leaves the impression that anxiety, if confronted directly, period and then systematically reducing the length of that
could not be managed by any other means. period. Worry scheduling also may be helpful because it
eliminates worry during periods in which it may be more
Cognitive Restructuring interfering (e.g., at work, in bed). Thought stopping (e.g.,
Cognitive restructuring is based on the idea that GAD interrupting unwanted worry by saying “stop” or snapping
is attributable in part to interpretations that do not reflect a rubber band that is worn around one’s wrist) may also be
a realistic appraisal of a situation. Two types of distortions used to eliminate worry at inappropriate times.
are common among patients with GAD: (1) believing that The use of skill-building techniques in GAD is based
unlikely events are likely to occur and (2) assuming that on the idea that some worries are based on realistic, reme-
the only possible outcome is the most catastrophic alterna- diable skill deficits. Examples may include problem solv-
tive. In part, anxious thinking is habitual in patients with ing, time management/activity scheduling, organizational
GAD; a treatment goal is to increase awareness of and al- skills, and social skills training. This issue will be dis-
ter this cognitive habit. In addition, thoughts and emotions cussed further in relation to recent modifications of CBT
form a vicious cycle; anxious mood increases the percep- below.
tion of threat and fear-provoking interpretations of ambig-
uous stimuli, which leads to further anxious mood. Thus, EFFICACY OF CBT FOR GAD
another goal of therapy is to interrupt this process.
7–10
Cognitive restructuring involves 3 steps. First, the ther- There are 4 major meta-analyses of CBT for GAD,
apist will help the client to identify anxious interpretations so there is no need for a separate comprehensive review of
or predictions by use of exemplars, questioning, review of GAD treatment studies here. Rather, it is useful to exam-
self-monitoring, or role playing. Next, the patient and ine the conclusions that can be drawn from these studies. A
therapist will develop an alternative thought that is real- compilation of effect sizes from all 4 studies is presented
istic and evidence-based, and the patient will actively in Table 1.
substitute this thought for the initial anxiety-provoking The earliest reviews established that CBT significantly
thought. Finally, a behavioral experiment will be devel- reduces anxiety and is superior to no treatment and to con-
oped to test the validity of the competing thoughts. The ditions used to control for nonspecific effects. There was
© COPYRIGHT 2004 PHYSICIANS POSTGRADUATE PRESS, INC. © COPYRIGHT 2004 PHYSICIANS POSTGRADUATE PRESS, INC.
J Clin Psychiatry 2004;65 (suppl 13) 15
Ariel J. Lang
Table 1. Summary of Effect Sizes for Reduction in Anxiety package to be better than behavioral or cognitive tech-
and Depression After Cognitive-Behavioral Therapy for niques alone (20% at posttreatment, 43% at follow-up).
Generalized Anxiety Disorder Treatment-related gains were always maintained or in-
Study Treatment Posttreatment Follow-up creased over the follow-up period. An overall dropout rate
7
Chambless and Gillis, 1993 CBT 1.69 1.95 of 8.3% suggests that CBT is well tolerated.
8
Borkovec and Whisman, 1996 In summary, these meta-analyses clearly demonstrate
Hamilton anxiety CBT 2.13 2.50 that CBT reduces anxiety symptoms and is more effective
BT 1.71 1.87
CT 1.30 … than no treatment and nonspecific controls. There is some
Nonspecific 1.78 2.35 suggestion that the full CBT package is better than behav-
None 0.03 … ioral or cognitive components alone, but this has not been
Hamilton depression CBT 1.41 1.66
BT 1.44 1.11 consistently demonstrated. Some of the factors that have
CT 1.12 … been associated with poor treatment response include con-
Nonspecific 0.88 1.13 current use of anxiolytic medication (type not specified),
None 0.07 …
Gould et al, 199710 CBT 0.91 … comorbid diagnoses, chronic social stressors, and negative
BT 0.51 … 11
CT 0.59 … expectations about therapy. Cognitive-behavioral therapy
9 for GAD is a good example, however, of the discrepancy
Borkovec and Ruscio, 2001 between statistically and clinically significant change.
Hamilton anxiety, STAI CBT 2.48 2.44
BT or CT 1.72 1.71 11
Placebo or alt 2.09 2.00 Durham and Allen reviewed clinical significance of
WL or none 0.01 … change in studies conducted between 1980 and 1993. When
Hamilton depression, BDI CBT 1.14 1.22 they examined the percentage of improvement, they found
BT or CT 1.02 0.88 an overall 50% reduction in somatic symptoms and 25% in
Placebo or alt 0.78 1.05 tendency to worry. Return to normal functioning occurred
WL or none 0.14 … for 57% of patients who took part in cognitive therapy and
Abbreviations: BDI = Beck Depression Inventory, BT = behavioral 22% receiving behavioral therapy, leading these authors to
therapy, CBT = cognitive-behavioral therapy, CT = cognitive
therapy, STAI = State Trait Anxiety Inventory, WL = wait list express a preference for cognitive approaches. To date, ac-
(control group). Symbol: … = no data available. 12
cording to Roemer and Orsillo, no studies have evaluated
the effect of CBT on broader measures of functioning, such
as quality of life and impairment.
evidence that CBT for GAD reduces depression symptoms
as well. Treatment effects were found to endure or in- RECENT MODIFICATIONS OF CBT FOR GAD
crease in the 6 to 12 months after the completion of treat-
7,8 10
ment. Gould et al. completed comparisons of a number Recognition of the limited clinical significance of
of treatment packages—purely behavioral, purely cogni- change associated with CBT for GAD has led to several re-
tive, and combined approaches. Although they found that cent efforts to refine the intervention. Two such attempts
the effect sizes of behavioral and cognitive approaches involve refinement of the cognitive aspects of treatment.
13
were smaller than those associated with CBT, there were Ladouceur et al. have devised a 4-component model of
no significant differences between approaches. The one GAD, which includes intolerance of uncertainty, erroneous
exception was that CBT performed better than relaxation beliefs about worry, poor problem orientation, and cogni-
training with biofeedback. These reviewers also found that tive avoidance. The resulting treatment approach is entirely
response to individual and group modalities did not sig- focused on reducing worry; the authors believe that relax-
nificantly differ and that length of intervention was not ation strategies are not a necessary component of treatment.
significantly associated with outcome. In their initial trial of the approach, they successfully re-
The most recent meta-analysis comprised 13 controlled duced symptoms (including worry, somatic symptoms,
9
clinical trials. The reviewers examined a number of meth- general anxiety, and depression) as compared with wait list
odological issues about each of the studies, including what (delayed treatment group). The intervention has yet to be
method was used for diagnosis, whether reliability checks compared with an active control.
were used, whether assessors were blinded, whether treat- A similar cognitive treatment involves addressing
ment was conducted according to a protocol, and whether metacognitive processes in GAD. In other words, beliefs
treatment was checked for adherence to protocol. They about worry are viewed as a critical factor in GAD. Both
concluded that the body of work was “characterized by a positive (e.g., worry prevents bad things from happening)
relatively high degree of scientific rigor.”9(p39) Every study and negative (e.g., worry will make me go crazy) beliefs
showed CBT to be better than no treatment. A majority of about worry are viewed as reinforcing the worry, thus
studies found CBT to be superior to alternative psycho- maintaining the disorder. The resulting intervention is en-
therapeutic treatments (82% at posttreatment and 78% at tirely cognitive; the key treatment goal is to address beliefs
9 5
follow-up). A minority found the full CBT treatment about worry.
© COPYRIGHT 2004 PHYSICIANS POSTGRADUATE PRESS, INC. © COPYRIGHT 2004 PHYSICIANS POSTGRADUATE PRESS, INC.
16 J Clin Psychiatry 2004;65 (suppl 13)
Treating GAD With CBT
Another approach to refining CBT for GAD has been primary clinical concern. Symptoms of other disorders
to add components to remedy deficits that may maintain the may interfere with selected treatment. For example, a de-
disorder. One example is the interpersonal approach to pressed patient may not have the motivation or energy to
GAD. Adherents to this model believe that people with follow through with homework assignments, or a panic
GAD engage in behaviors that make negative interpersonal patient may experience relaxation-induced anxiety when
2
outcomes more likely. As a result, components are added to using symptom management techniques. Substance use
the treatment to improve maladaptive patterns of relating to may provide a competing (albeit less helpful) strategy for
14
and interacting with others. Another approach is based on reducing anxiety, thus reducing compliance with treat-
the view that individuals with GAD have difficulty with ment. If it is the case that another disorder is causing more
regulating emotion. Specifically, GAD is seen as an out- distress or impairment, referring the patient to services for
growth of difficulty with modulation of emotion and at- the primary diagnosis is most appropriate. If another dis-
tention to cognitive information as a technique to avoid order is equally disabling but the patient is motivated to
emotional information. Based on this conceptualization, address the GAD, supplementing the cognitive-behavioral
techniques such as education about emotions and training approach for GAD with techniques to address the addi-
in regulating emotion have been added to intervention tional problem may be useful.
packages to decrease discomfort with emotion and allow
more adaptive problem solving, thus reducing the need for Older Adults
15
worry. The elderly are an important population to consider in
Mindfulness and acceptance strategies have been incor- relation to treatment for GAD because prevalence rates are
12,16 19
porated into treatment for GAD as well. The rationale high in this group. There are 2 reasons to consider modi-
for this approach is as follows. Worried individuals are con- fication of the basic CBT approach for use with older
tinually focused on what is perceived as a threatening fu- adults. First, GAD presents somewhat differently in older
ture. Worry tends to be self-perpetuating (i.e., the more adults than it does in younger individuals. Research has
worried one is, the more anxious he or she feels, the more shown that there are age-related differences in content of
likely he or she is to perceive ambiguous stimuli as threat- worry, description and/or experience of anxiety, and em-
19
ening, etc.) and can interfere with effective cognitive phasis placed on somatic symptoms. Second, CBT may
strategies such as problem solving. Acceptance-based ap- be less effective for older adults. Dropout rates are higher
proaches encourage patients to accept that some events are than those observed among younger populations, and the
outside of their control, which may compel them to accept effectiveness of CBT has not been shown to surpass alter-
19,20
that reality. Moreover, patients are often asked to identify native approaches such as supportive therapy.
highly valued aspects of their life with which they may Some strategies that have been suggested for enhancing
have difficulties and to use problem solving to make the effectiveness of CBT for the elderly include use of
17
changes in those areas. Mindfulness, a psychological/ adapted materials, such as large-type handouts or multi-
behavioral version of meditation, is applied to increase re- media presentations; techniques to enhance memory for
laxation and counteract the future orientation of individuals presented material, such as audiotapes or videotapes to be
with GAD. Preliminary testing suggests that this approach reviewed between sessions; visual imagery in the place of
12
may lead to positive change in symptoms and functioning. other relaxation techniques; and planning for contingen-
These modifications of the cognitive-behavioral ap- cies such as energy level, physical functioning, and
proach to treating GAD are at preliminary stages of devel- weather, which may affect the elderly person’s ability to
21
opment. Future work should test the effectiveness of such attend an appointment. Others are considering alterna-
modifications, particularly in relation to clinically signifi- tive approaches, such as stimulus control, problem solv-
cant change and broad functional outcomes. ing, and life review, for managing anxiety in this popula-
20
tion.
SPECIAL CONSIDERATIONS
IN USING CBT FOR GAD COMBINING THERAPEUTIC APPROACHES
Comorbid Diagnoses Most patients who seek psychotherapy for anxiety dis-
The presence of comorbid diagnosis is normative in pa- orders are taking an anxiolytic medication, and the major-
tients with GAD. Among the most common lifetime comor- ity express a preference for a combined treatment ap-
22
bid diagnoses are major depression, panic disorder, and proach. Although it is intuitively reasonable to believe
18
substance abuse. The presence of 1 or more of these con- that 2 modalities would be better than 1, this idea has not
ditions may complicate successful treatment of GAD using received consistent empirical support. To date, only 2
22,23
CBT. studies have compared the combination of medication
23
The most important factor to consider in treating GAD and CBT with medication and CBT alone. Power et al.
in the presence of another disorder is whether it is the conducted a study involving 5 treatment groups: CBT, di-
© COPYRIGHT 2004 PHYSICIANS POSTGRADUATE PRESS, INC. © COPYRIGHT 2004 PHYSICIANS POSTGRADUATE PRESS, INC.
J Clin Psychiatry 2004;65 (suppl 13) 17
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