Cognitive and Behavioral Therapies for Generalized Anxiety Disorder

Status: Strong Research Support

Description

Cognitive and behavioral therapies for generalized anxiety disorder (GAD) refer to a variety of techniques that can be provided individually or in combination. The basic premise underlying the therapy approaches is that thoughts, feelings and behaviors are inter-related, so altering one can help to alleviate problems in another (e.g., changing negative thinking will lead to less anxiety). The excessive, uncontrollable worry that is the hallmark of GAD is thought to be maintained through maladaptive thinking about the utility of worrying, a tendency to repeat worries instead of problem-solving, difficulties relaxing, and unhealthy behaviors, including attempted avoidance of negative thoughts and images, as well as situations that might provoke worry. The cognitive therapy techniques focus on modifying the catastrophic thinking patterns and beliefs that worrying is serving a useful function (termed cognitive restructuring). The behavioral techniques include relaxation training, scheduling specific ‘worry time’ as well as planning pleasurable activities, and controlled exposure to thoughts and situations that are being avoided. The purpose of these exposures is to help the person learn that their feared outcomes do not come true, and to experience a reduction in anxiety over time.

The research evidence suggests that both cognitive or behavior therapy on their own can be helpful for GAD (especially cognitive restructuring or applied relaxation). However, there may be some advantage to combining the approaches, with some studies finding that the treatment is more powerful when therapy involves cognitive work, exposures and relaxation. Cognitive Behavior Therapy (CBT) typically refers to a combination of the various cognitive and behavioral approaches, and ‘Anxiety Management Training’ usually refers to the particular combination of relaxation and cognitive restructuring. The therapies can be conducted individually or with a group, and CBT is helpful for older adults with GAD as well. Typically, CBT will be conducted in weekly sessions of 1–2 hours over the course of approximately 4 months, for a total of 16–20 hours of treatment.

Key References (in reverse chronological order)

• Clinical trials emphasizing the utility of CBT, cognitive therapy (mainly cognitive restructuring), or behavior therapy (mainly applied relaxation)
• Borkovec, T. D., Newman, M. G., Pincus, A. L., & Lytle, R. (2002). A component analysis of cognitive– behavioral therapy for generalized anxiety disorder and the role of interpersonal problems. Journal of Consulting and Clinical Psychology, 70, 288–298. https://doi.org/10.1037/0022-006X.70.2.288
• Kohli, A., Nehra, V., & Nehra, R. (2000). Comparison of efficacy of psychorelaxation and pharmacotherapy in generalized anxiety disorder. Journal of Personality and Clinical Studies, 16, 43–48. https://psycnet.apa.org/record/2000-07910-007
• Ladouceur, R., Dugas, M. J., Freeston, M. H., Le´ger, E., Gagnon, F., & Thibodeau, N. (2000). Efficacy of cognitive– behavioral treatment of generalized anxiety disorder: Evaluation in a controlled clinical trial. Journal of Consulting and Clinical Psychology, 68, 957–964. https://doi.org/10.1037/0022-006X.68.6.957
• Öst, L.-G., & Breitholtz, E. (2000). Applied relaxation vs. cognitive therapy in the treatment of generalized anxiety disorder.  Behaviour Research and Therapy, 38, 777-790. https://doi.org/10.1016/S0005-7967(99)00095-9
• Borkovec, T. D., & Costello, E. (1993). Efficacy of applied relaxation and cognitive–behavioral therapy in the treatment of generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 61, 611–619. https://doi.org/10.1037/0022-006X.61.4.611
• Barlow, D. H., Rapee, R. M., & Brown, T. A. (1992). Behavioral treatment of generalized anxiety disorder. Behavior Therapy, 23, 551–570. https://doi.org/10.1016/S0005-7894(05)80221-7
• White, J., Keenan, M., & Brooks, N. (1992). Stress control: A controlled comparative investigation of large group therapy for generalized anxiety disorder. Behavioural Psychotherapy, 20, 97–114. https://doi.org/10.1017/S014134730001689X
• Butler, G., Fennell, M., Robson, P., & Gelder, M. (1991). Comparison of behavior therapy and cognitive behavior therapy in the treatment of generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 59, 167–175. https://doi.org/10.1037/0022-006X.59.1.167
• Power, K. G., Simpson, R. J., Swanson, V., & Wallace, L. A. (1990). A controlled comparison of cognitive–behaviour therapy, diazepam, and placebo, alone and in combination, for the treatment of generalized anxiety disorder. Journal of Anxiety Disorders, 4, 267–292. https://doi.org/10.1016/0887-6185(90)90026-6
• Borkovec, T. D., Mathews, A. M., Chambers, A., Ebrahimi, S., Lytle, R., & Nelson, R. (1987). The effects of relaxation training with cognitive or nondirective therapy and the role of relaxation-induced anxiety in the treatment of generalized anxiety. Journal of Consulting and Clinical Psychology, 55, 883–888. https://doi.org/10.1037/0022-006X.55.6.883
• Meta-analyses (statistical summaries of clinical trials) of CBT:
• Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17-31. https://doi.org/10.1016/j.cpr.2005.07.003
• Mitte, K. (2005). Meta-analysis of cognitive-behavioral treatments for generalized anxiety disorder: a comparison with pharmacotherapy. Psychological Bulletin, 131, 785–95. https://doi.org/10.1037/0033-2909.131.5.785
• Gould, R. A., Safren, S. A., O'Neill Washington, D., & Otto, M. W. (2004). A meta-analytic review of cognitive-behavioral treatments. In R. G. Heimberg, C. L. Turk, and D. S. Mennin (Eds), Generalized anxiety disorder: Advances in research and practice. New York: Guilford Press. https://psycnet.apa.org/record/2004-16375-010
• Borkovec, T. D., & Ruscio, A. M. (2001). Psychotherapy for generalized anxiety disorder. Journal of Clinical Psychiatry, 62, 37-42. https://www.psychiatrist.com/jcp/psychotherapy-generalized-anxiety-disorder/
• Gould, R. A., Otto, M. W., Pollack, M. H., & Yap, L. (1997). Cognitive behavioral and pharmacological treatment of generalized anxiety disorder: A preliminary meta-analysis. Behavior Therapy, 28, 285–305. https://doi.org/10.1016/S0005-7894(97)80048-2
• Future directions in therapies for GAD:
• Recent advances in therapies for GAD are promising, including the use of emotion regulation, acceptance-based and mindfulness approaches, an integrative therapy (that incorporates specific strategies to address interpersonal problems and emotional avoidance), as well as a metacognitive perspective. However, there is not yet sufficient research evidence to list these approaches as empirically-supported. Similarly, CBT offered over the computer may be of value, but further research is necessary.
• Roemer, L., Orsillo, S. M. (2007). An open trial of an acceptance-based behavior therapy for generalized anxiety disorder. Behavior Therapy, 38, 72-85. https://doi.org/10.1016/j.beth.2006.04.004
• Wells, A., & King, P. (2006). Metacognitive therapy for generalized anxiety disorder: An open trial. Journal of Behavior Therapy and Experimental Psychiatry, 37, 206-212. https://doi.org/10.1016/j.jbtep.2005.07.002
• Mennin, D.S. (2006). Emotion regulation therapy: An integrative approach to treatment-resistant anxiety disorders. Journal of Contemporary Psychotherapy, 36, 95-105. https://doi.org/10.1007/s10879-006-9012-2
• Newman, M. G., Castonguay, L. G., Borkovec, T. D., Fisher, A. J., & Nordberg, S. S. (2008). An open trial of integrative therapy for generalized anxiety disorder. Psychotherapy: Theory, Research, Practice, Training, 45(2), 135–147. https://doi.org/10.1037/0033-3204.45.2.135

Clinical Resources

• See description of CBT techniques in the following clinical resource/manual:
• Borkovec, T. D., & Costello, E. (1993). Efficacy of applied relaxation and cognitive–behavioral therapy in the treatment of generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 61, 611–619. https://doi.org/10.1037/0022-006X.61.4.611
• Brown, T., O'Leary, T., & Barlow, D.H. (2007). Generalized anxiety disorder. In D.H. Barlow (Ed.), Clinical handbook of psychological disorders (Fourth Edition). New York: Guilford Press.
• Zinbarg, R. E., Craske, M. G., & Barlow, D. H. (2006). Mastery of your anxiety and worry: Therapist guide (Second Edition). Oxford University Press. https://doi.org/10.1093/med:psych/9780195300024.001.0001
• See description of relaxation training in the following clinical resource/manual:
• Hazlett-Stevens, H., & Bernstein, D. A. (2022). Progressive relaxation training: A guide for professionals, students, and researchers. Bloomsbury Publishing. https://www.bloomsbury.com/us/progressive-relaxation-training-9781440873812/
• Lazarus, A. (1972). Behavior therapy and beyond. New York: Random House.
• Öst, L.-G. (1987). Applied relaxation: Description of a coping technique and review of controlled studies. Behaviour Research and Therapy, 25, 397–409. https://doi.org/10.1016/0005-7967(87)90017-9
• Wolpe, J. (1969). The practice of behavior therapy (First Edition). New York: Pergamon. https://www.amazon.com/practice-behavior-therapy-Pergamon-psychology/dp/0080364551
• See description of cognitive techniques in the following clinical resource/manual:
• Beck, A. T., & Emery, G., with Greenberg, R. L. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books. https://www.hachettebookgroup.com/titles/aaron-beck/anxiety-disorders-and-phobias/9780465005871/?lens=basic-books
• Wells, A. (1997). Cognitive therapy of anxiety disorders: A practice manual and conceptual guide. Chichester, England: Wiley. https://www.amazon.com/Cognitive-Therapy-Anxiety-Disorders-Conceptual/dp/047196476X
• See description of CBT with older adults in the following clinical resource/manual:
• Gorenstein, E. E., Papp, L. A., & Kleber, M. S. (1999). Cognitive–behavioral treatment of anxiety in later life. Cognitive Behavior Practice, 6, 305–319. https://doi.org/10.1016/S1077-7229(99)80050-9

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