Cbt

1. 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)

2. 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.

3. 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

4. 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

5. Core Patterns in GAD
• Uncontrollable worry
• Future orientation
• Negative cognitive biases
• Somatic arousal
• Role and task inefficiency
• Interpersonal aversiveness (unbalanced
relationships)

6. 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

7. 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

8. Meta-Analysis of Randomized Anxiety
Trials of CBT (within ES)
Norton & Price, 2007, JNMD
Effect
Size
(d)

9. 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)

11. Meta-Analysis of Controlled Trials of CBT
(Between ES)
Hofmann & Smits, 2008, J Clin Psychiatry
Effect
Size
(g)

12. 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

13. Meta-Analysis of CBT – Gould et al., 2004
Between Groups
Effect
Size
(d)

14. Specificity of Treatment
(Siev & Chambless, 2007, JCCP)
• GAD CT = RT
• Panic Disorder CT* > RT
• Cognitive Therapy (CT) includes interoceptive exposure
• Relaxation Therapy (RT)

15. 0
0.5
1
1.5
2
2.5
3
PTSD OCD SAD Panic GAD Agor
Meta-Analyses of Effectiveness Studies
(Within ES) (Stewart & Chambless, 2009, JCCP)
Effect
Size
(d)

16. 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

17. 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)

18. 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.”

19. 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

20. 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; Hoehn-
Saric, 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)

21. 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

22. Borkovec
• Encourage a present focus vs. future (past)
– Leave patients expectancy free

23. 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)

24. 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)

25. Intolerance of Uncertainty
• Motivates unnecessary worry-based planning
– “What if X happens, could I cope by…”

26. 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

27. Treatment Elements
Borkovec
1. Awareness and self-monitoring
2. Relaxation
3. Cognitive therapy
4. Imagery rehearsal of coping strategies
(see Borkovec, 2006 for review)

28. 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)

29. 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)

30. Relaxation Strategies
• Progressive Relaxation (PR; e.g., Bernstein &
Borkovec, 1973)
• Applied Relaxation (AR;O¨ st, 1987).
– AR does include exposure elements

31. Mechanism of Relaxation Training
(Ost, 1992)
• Reduces general tension and anxiety (and link
stressor/panic)
• Enhances awareness about how anxiety works, de-
mystifying and diminishing its impact
• Enhances self-efficacy : individuals feel equipped
to cope with anxiety

32. 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

33. 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 cognitive-
restructuring

34. Cognitive Restructuring
• Self monitoring
• Logical analysis
• Probability overestimations
• Overestimations of the degree of catastrophe
– Ability to cope

35. 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)

36. Mindfulness –
• Curious attention to the present moment, in
an open, nonjudgmental, and accepting
manner
– (Bishop et al., 2004; Germer, 2005; Kabat-Zinn, 1994)

37. 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

38. 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

39. 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”

40. 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

41. 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)

42. 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)

43. New Directions
• Attentional training
• Mindfulness/emotional tolerance training
• Interoceptive exposure
• Integrative treatment

44. GAD Interpersonal Roles
• Polarizing the relationship: the worry partner
• Improving couple’s problem-solving

45. 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