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

Effectiveness and predictors of group cognitive behaviour therapy outcome for generalised anxiety disorder in an out-patient hospital setting

BACKGROUND

Cognitive behavioural therapy (CBT) is an empirically supported treatment for generalized anxiety disorder (GAD). Little is known about the effectiveness of CBT for GAD in real-world treatment settings.

AIM

This study investigated the effectiveness of group CBT and predictors of treatment response in an out-patient hospital clinic.

METHOD

Participants (n = 386) with GAD participated in 12 sessions of group CBT at an out-patient clinic. Of those who provided at least partial data (n = 326), 84.5% completed treatment. Most questionnaires were completed at pre- and post-treatment; worry severity was assessed weekly.

RESULTS

Group CBT led to improvements in chronic worry (d = -0.91, n = 118), depressive symptoms (d = -1.22, n = 172), GAD symptom severity (d = -0.65, n = 171), intolerance of uncertainty (IU; d = -0.46, n = 174) and level of functional impairment (d = -0.35, n = 169). Greater pre-treatment GAD symptom severity (d = -0.17, n = 293), chronic worry (d = -0.20, n = 185), functional impairment (d = -0.12, n = 292), and number of comorbid diagnoses (d = -0.13, n = 299) predicted greater improvement in past week worry over treatment. Biological sex, age, depression symptom severity, number of treatment sessions attended, and IU did not predict change in past week worry over time.

DISCUSSION

These findings provide support for the effectiveness of group CBT for GAD and suggest the outcomes are robust and are either not impacted or are slightly positively impacted by several demographic and clinical factors.

The effectiveness of transdiagnostic cognitive behavioural therapy for anxiety disorders: the role of and impact of comorbid depression

Transdiagnostic Cognitive Behaviour Therapy (tCBT), an intervention designed to be applicable across multiple diagnoses, was introduced to improve limitations in traditional therapy such as cost and access to trained therapists. It has been established as an effective and efficacious treatment for anxiety disorders, though there has been little research focussed on the role of depression. The current study investigated the role of comorbid depression during tCBT for anxiety disorders in primary care settings as an outcome and a moderator of anxiety outcomes. Results of multi-level ANOVAs indicated no significant difference in anxiety outcomes regardless of whether there was a comorbid depression diagnosis in the tCBT condition, and that individuals with a comorbid depression diagnosis experienced significantly greater reduction in anxiety severity than those without. Depression symptom severity decreased to a significantly greater extent in the tCBT condition than in TAU when the outcome measure of Patient Health Questionnaire was utilised as the outcome measure, but this was not mirrored when the Clinician Severity Rating was utilised as the outcome measure. This study provides preliminary support for the effectiveness of Transdiagnostic Cognitive Behaviour therapy for those with both a principal anxiety disorder and comorbid depression in symptom reduction.

Predictors and moderators of treatment outcome in late-life anxiety: A systematic review

BACKGROUND

The aim of this review was to identify and critically appraise predictors and moderators of outcomes of psychological and pharmacological treatments for late-life anxiety disorders. Their identification may guide the development of personalised treatments for older people with anxiety disorders.

METHODS

Web of Science, PsychINFO, CINAHL, Embase, and Pubmed were searched for studies published up to 12 May 2022. Randomised controlled trials and observational studies reporting treatment predictors and moderators were included. Participants with a diagnosis of any anxiety disorder who were aged over 60 years were included. Treatment outcomes included response, remission, and change in anxiety score.

RESULTS

Thirteen studies met the inclusion criteria. Twenty-three out of 49 predictors or moderators assessed at post-treatment, and 14 out of 33 predictors or moderators assessed at follow-up were statistically significant. Only one predictor, baseline worry severity at post-treatment, was reported in at least three studies. Most studies were rated as having a low risk of bias in at least three areas and satisfied important quality criteria for predictor and moderator analyses.

LIMITATIONS

Samples were predominantly white, female and highly educated, and most studies were secondary analyses.

CONCLUSIONS

There is evidence that baseline worry severity appears to predict treatment outcome in late-life anxiety disorders. However, this was only explored in psychological intervention studies and therefore its predictive ability in pharmacotherapy remains unknown. Future research should explore predictors and moderators in a range of anxiety disorders and design methodologically-strong and adequately-powered studies with the primary aim of assessing predictors of treatment outcomes.

Psychological interventions for generalized anxiety disorder: Effects and predictors in a naturalistic outpatient setting

OBJECTIVE

Numerous randomized controlled trials (RCTs) demonstrate the efficacy of cognitive behavioral therapy (CBT), metacognitive therapy (MCT), and methods to reduce intolerance of uncertainty (IU-CBT) in the treatment of generalized anxiety disorder (GAD). However, few studies have investigated these treatments under conditions of routine clinical care. The main objective of this study was to investigate the effectiveness of psychotherapy for GAD in an outpatient setting and to identify factors influencing treatment outcome.

METHODS

Fifty-nine GAD patients received naturalistic CBT (including MCT and IU-CBT) in an outpatient clinic and postgraduate training center for psychotherapy. Patients completed self-report questionnaires at the beginning and end of therapy regarding the main outcome worry as well as metacognitions, intolerance of uncertainty, depression, and general psychopathology.

RESULTS

Worry, negative metacognitions, intolerance of uncertainty, depression, and general psychopathology decreased significantly (p's < .001) with large effect sizes for all symptoms (d = 0.83-1.49). A reliable change in the main outcome worry was observed in 80% of patients, and recovery occurred in 23%. Higher worry scores at posttreatment were predicted by higher pretreatment scores, female sex, and less change in negative metacognitive beliefs during treatment.

CONCLUSIONS

Naturalistic CBT for GAD appears to be effective in routine clinical care for worry as well as depressive symptoms, with particular benefits associated with altering negative metacognitions. However, a recovery rate of only 23% is lower than the rates reported in RCTs. Treatment needs to be improved, especially for patients with more severe GAD and for women.

Therapists' perceptions of interpersonally challenging patients in generalized anxiety disorder

OBJECTIVE

This study explores in cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD) to what degree therapists' perceptions of their patients as interpersonally challenging (IC) is explained by the therapist or patient effects, if baseline patients' characteristics predict IC, and if IC is related to outcome.

METHOD

Eighty patients diagnosed with GAD and treated by 20 therapists with 16 sessions of CBT were randomized to two different implementation conditions. Patients completed baseline measures of depression, anxiety, interpersonal problems, and interpersonal strengths. The therapists completed a single-item assessing IC session-by-session. As an outcome, patients completed a worry measure at baseline, session 5, session 10, and posttreatment.

RESULTS

Multilevel models showed meaningful therapist effects, explaining 18% of IC variance. Interpersonal strengths were the only baseline predictor significantly and negatively associated with IC during treatment. Structural equation models showed significant negative IC effects on subsequent patient worry during therapy.

CONCLUSIONS

IC might represent a risk factor for psychotherapy outcome. Patient interpersonal strengths at baseline may buffer therapists perceiving their patients as ICs. The therapist effects on IC suggest that CBT clinicians treating GAD might benefit from identifying cases that are interpersonally challenging for them and reflecting about what might trigger that perception.

Psychotherapeutic treatments for generalized anxiety disorder: cognitive and behavioral therapies, enhancement strategies, and emerging efforts

INTRODUCTION

Generalized anxiety disorder (GAD) is common and disabling. Different versions of cognitive behavioral therapy (CBT) have been tested, but no treatment works for everyone. Therefore, researchers have attempted approaches to enhance CBT.

AREAS COVERED

The current narrative review examines meta-analyses and individual trials of CBT-based treatments for GAD. We focus on CBT and its cognitive and behavioral components as well as efforts to enhance CBT and its dissemination and generalizability. Enhancement efforts included interpersonal and emotional processing therapy, mindfulness-based CBT, emotion regulation therapy, intolerance of uncertainty therapy, the unified protocol, metacognitive therapy, motivational interviewing, and contrast avoidance targeted treatment. Emerging strategies to enhance dissemination have focused on technologically based treatments. Attempts at generalizability have included examination of efficacy within diverse racial and ethnic groups.

EXPERT OPINION

We conclude that CBT is efficacious, and a number of enhancement efforts have shown some promise in improving upon CBT in single trials. However, more research is needed, particularly efforts to determine which enhancements work best for which individuals and what are the mechanisms of change. Furthermore, few technological interventions have been compared to active treatments. Finally, much more attention needs to be paid to ethnic and racial diversity in randomized controlled trials.

Worry-specific versus self-tailored internet-based treatments for generalized anxiety disorder, with scheduled support or support on demand: A pilot factorial design trial

Studies suggest that internet-delivered cognitive behaviour therapy (ICBT) can be effective when treating generalized anxiety disorder (GAD). This pilot factorial design study examined the effects of two types of ICBT (worry-specific and self-tailored treatment), and two support types (scheduled weekly support and support on demand), on measures of worry, anxiety, and depressive symptoms. Participants (N = 85) were randomized into four treatment groups. Post-treatment measures were completed by 76.5% after eight weeks (n = 65). Intention to treat analysis showed significant improvements, with moderate to large within-group effects on the primary outcome measure, Penn State Worry Questionnaire (Cohen's d = 0.77-1.43). Minor to large effects on the secondary measures were found in all groups (Cohen's d = 0.13-1.66). No significant differences in outcome measures were found between the groups. Receiving scheduled support and self-tailored treatment was rated as more positive than receiving support on demand and the worry-specific program. A limitation is the low number of participants. The pilot results suggest that GAD can be treated with both worry-specific and self-tailored treatments, and that ICBT can be supported both with scheduled and support on demand.

Neural mechanisms and predictors of SSRI and CBT treatment of anxiety: A randomized trial focused on emotion and cognitive processing

Anxiety disorders (ADs) are common and difficult to treat. While research suggests ADs are characterized by an imbalance between bottom-up and top-down attention processes and that effective treatments work by correcting this dysfunction, there is insufficient data to explain how and for whom treatments work. The late positive potential (LPP), an event-related potential reflecting elaborative processing of motivationally salient stimuli, is sensitive to both bottom-up and top-down processes. The present study examines the LPP in healthy controls (HC) and patients with ADs under low and high working memory (WM) load to assess its utility as a predictor and index of symptom reduction in patients who underwent cognitive behavioral therapy (CBT) or selective serotonin reuptake inhibitor (SSRI) treatment. The LPP when viewing negative and neutral distractor images and WM performance were assessed in 96 participants (40 HC, 32 CBT, 24 SSRI) during a letter recall task at Week 0 and in a subset of the study sample (23 CBT, 16 SSRI) at Week 12. Patients were randomly assigned to twelve weeks of CBT or SSRI treatment. Participants completed self-reported symptom measures at each time point. Greater Week 0 LPP to negative images under low WM load predicted greater symptom reduction in the SSRI, but not the CBT, group. Regression analyses examining the LPP to negative images as an index of symptom reduction revealed a smaller decrease in the LPP to negative images under low WM load was associated with less anxiety reduction across treatment modalities. Findings suggest the LPP during low WM load may serve as a cost-effective predictor and index of treatment outcome in ADs. Clinical Trials Registration: ClinicalTrials.gov (Identifier: NCT01903447).

Individualized Homeopathic Medicines in the Treatment of Generalized Anxiety Disorder: A Double-Blind, Randomized, Placebo-Controlled, Pilot Trial

INTRODUCTION

Evidence favoring homeopathy in generalized anxiety disorder (GAD) remains scarce. The objective of this pilot trial was to test feasibility of a definitive trial in future. We also experimented whether individualized homeopathic medicines (IH) plus psychological counseling (PC) can produce significantly different effects beyond placebo plus PC in the treatment of GAD.

METHODS

A double-blind, randomized, placebo-controlled, parallel arm, pilot trial was conducted on 62 GAD patients at the National Institute of Homoeopathy, India. GAD-7 questionnaire and Hamilton Anxiety Scale (HAM-A) were used as the primary and secondary outcomes, respectively, measured at baseline and 3 months. Patients received either IH plus PC (n = 31) or identical-looking placebo plus PC (n = 31). Intention-to-treat sample was analyzed to detect group differences using unpaired t tests.

RESULTS

Recruitment and retention rates were 56 and 90%, respectively. Mean age was 31.5 years; 56.5% were male. GAD-7 reductions were non-significantly higher in IH than placebo (p = 0.122). Group differences on HAM-A favored IH significantly (p = 0.018). Effect sizes were small to medium. Calcarea carbonica was the most frequently indicated medicine. No serious adverse events happened.

CONCLUSIONS

A small but positive direction of anxiolytic effect was observed favoring homeopathy over placebo. A definitive trial appeared feasible in future.

Comparison of cognitive-behavioral therapy and yoga for the treatment of late-life worry: A randomized preference trial

BACKGROUND

The purpose of this study was to compare the effects of cognitive-behavioral therapy (CBT) and yoga on late-life worry, anxiety, and sleep; and examine preference and selection effects on these outcomes.

METHODS

A randomized preference trial of CBT and yoga was conducted in community-dwelling adults 60 years or older, who scored 26 or above on the Penn State Worry Questionnaire-Abbreviated (PSWQ-A). CBT consisted of 10 weekly telephone sessions. Yoga consisted of 20 biweekly group yoga classes. The primary outcome was worry (PSWQ-A); the secondary outcomes were anxiety (PROMIS-Anxiety) and sleep (Insomnia Severity Index [ISI]). We examined both preference effects (average effect for those who received their preferred intervention [regardless of whether it was CBT or yoga] minus the average for those who did not receive their preferred intervention [regardless of the intervention]) and selection effect (which addresses the question of whether there is a benefit to getting to select one intervention over the other, and measures the effect on outcomes of self-selection to a specific intervention).

RESULTS

Five hundred older adults were randomized to the randomized trial (125 each in CBT and yoga) or the preference trial (120 chose CBT; 130 chose yoga). In the randomized trial, the intervention effect of yoga compared with CBT adjusted for baseline psychotropic medication use, gender, and race was 1.6 (-0.2, 3.3), p = .08 for the PSWQ-A. Similar results were observed with PROMIS-Anxiety (adjusted intervention effect: 0.3 [-1.5, 2.2], p = .71). Participants randomized to CBT experienced a greater reduction in the ISI compared with yoga (adjusted intervention effect: 2.4 [1.2, 3.7], p < .01]). Estimated in the combined data set (N = 500), the preference and selection effects were not significant for the PSWQ-A, PROMIS-Anxiety, and ISI. Of the 52 adverse events, only two were possibly related to the intervention. None of the 26 serious adverse events were related to the study interventions.

CONCLUSIONS

CBT and yoga were both effective at reducing late-life worry and anxiety. However, a greater impact was seen for CBT compared with yoga for improving sleep. Neither preference nor selection effects was found.

The benefits of a longer course of cognitive behavioral therapy for some patients with social anxiety disorder

Historically, cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) has been evaluated in randomized-controlled trials as a 12-16 session treatment and has demonstrated response rates ranging from 58% to 75%. Despite these promising results, some patients do not improve substantially after this short course of CBT. It is unclear whether non-responding patients would make substantial improvements in social anxiety with further treatment. In a university outpatient clinic specializing in CBT for SAD, we compared outcomes for patients who ended treatment after approximately 20 sessions of CBT (n = 38) to those who continued treatment for a variable number of additional sessions (n = 34). We found no between-group differences in demographic characteristics, number of comorbid diagnoses, comorbid generalized anxiety disorder or major depressive disorder, or severity of depression at baseline. Patients who ended treatment after 20 sessions experienced greater improvements in SAD over those 20 sessions compared to those who continued treatment. Both groups experienced changes in depression and quality of life over the first 20 sessions. Those who continued treatment showed additional decreases in social anxiety beyond session 20. For those who initially appear to be non-responsive to CBT for SAD, a longer course of treatment may elicit significant improvements.

The dose-response curve in cognitive-behavioral therapy for anxiety disorders

Previous studies examining the dose-response curve in psychotherapy have suggested that 11-19 sessions may be necessary for at least 50% of individuals to show clinically significant improvement. However, this curve has not been examined specifically for cognitive-behavioral therapy (CBT) for anxiety disorders, for which a more rapid recovery curve may be expected. Survival analysis was used to assess the dose-response curve for 201 patients with anxiety disorders who received weekly CBT at an anxiety specialty clinic. The primary outcome measure was the Outcome Questionnaire-45.2, which patients completed prior to each treatment session. Sixty-four percent of the sample achieved reliable change, and this response occurred in approximately five sessions on average. Fifty percent of the sample achieved clinically significant improvement, which occurred in approximately eight sessions on average. The findings suggest that earlier response may be expected in CBT for anxiety disorders, and are discussed in terms of potential ways to further improve response rates for this treatment.

A Multiple-Baseline Evaluation of Acceptance and Commitment Therapy Focused on Repetitive Negative Thinking for Comorbid Generalized Anxiety Disorder and Depression

Repetitive negative thinking (RNT) is a core feature of generalized anxiety disorder (GAD) and depression. Recently, some studies have shown promising results with brief protocols of acceptance and commitment therapy (ACT) focused on RNT in the treatment of emotional disorders in adults. The current study analyzes the effect of an individual, 3-session, RNT-focused ACT protocol in the treatment of severe and comorbid GAD and depression. Six adults meeting criteria for both disorders and showing severe symptoms of at least one of them participated in the study. A delayed multiple-baseline design was implemented. All participants completed a 5-week baseline without showing improvement trends in emotional symptoms (Depression Anxiety and Stress Scale - 21; DASS-21) and pathological worry (Penn State Worry Questionnaire; PSWQ). The ACT protocol was then implemented, and a 3-month follow-up was conducted. Five of the six participants showed clinically significant changes in the DASS-21 and the PSWQ. The standardized mean difference effect sizes for single-case experimental design were very large for emotional symptoms (d = 3.34), pathological worry (d = 4.52), experiential avoidance (d = 3.46), cognitive fusion (d = 3.90), repetitive thinking (d = 4.52), and valued living (d = 0.92 and d = 1.98). No adverse events were observed. Brief, RNT-focused ACT protocols for treating comorbid GAD and depression deserve further empirical tests.

Changes in Decentering and Reappraisal Temporally Precede Symptom Reduction During Emotion Regulation Therapy for Generalized Anxiety Disorder With and Without Co-Occurring Depression

Emotion Regulation Therapy (ERT) has demonstrated efficacy in both open and randomized trials for generalized anxiety disorder (GAD) with and without co-occurring depression. An important goal in ERT is to teach clients adaptive emotion regulation, including healthier metacognitive abilities such as decentering and cognitive reappraisal. A few studies thus far have demonstrated a mediating role for these metacognitive abilities in other cognitive behavioral therapies (CBTs) for GAD. However, a drawback to most of these has been the ability to demonstrate a causal role for improved metacognitive abilities in outcome. In the present study, we utilized multilevel time-lagged segment analyses to explore the temporal dynamics between session-by-session changes in metacognition and anxiety outcomes from ERT. Thirty-one young adults diagnosed with GAD with and without co-occurring depression received 16 sessions of ERT. Prior to each session, participants completed questionnaires pertaining to metacognition (i.e., decentering and cognitive reappraisal) and anxiety symptoms (i.e., worry, trait anxiousness, and generalized anxiety). Changes in decentering temporally preceded changes in worry and trait anxiousness of a medium to large magnitude, and changes in cognitive reappraisal temporally preceded changes in all three outcomes of a medium to large magnitude. The reverse direction, where mediators were predicted by outcomes, was nonsignificant. These findings support the notion that adaptive metacognitive emotion regulation is involved in reducing worry and anxiety in GAD. Having a clearer understanding of the temporal dynamics between metacognitive abilities and symptoms of anxiety can inform and improve not only ERT but other CBTs for GAD, as well.

Time-varying moderation of treatment outcomes by illness duration and comorbid depression in generalized anxiety disorder

OBJECTIVE

To extend the sparse literature on moderators, we used time-varying effect modeling (TVEM; Tan, Shiyko, Li, Li, & Dierker, 2012) to examine how depressive symptoms and duration of generalized anxiety disorder (GAD) moderated effects of 3 treatments for GAD (applied relaxation [AR], cognitive-behavioral therapy [CBT], and nondirective therapy [ND]) over time using intensive repeated measures.

METHOD

In a secondary analysis of Borkovec and Costello (1993), 66 GAD clients were randomly assigned to AR (n = 23), CBT (n = 23), or ND (n = 20). Clients received 12 therapy sessions over 6 weeks, and after 2 weeks of posttreatment assessment, had 2 additional weekly fading sessions. They completed thrice daily anxiety ratings during this 10-week period. GAD duration (Anxiety Disorders Interview Schedule-Revised) and depressive symptoms (Hamilton Depression Rating Scale) were assessed at baseline.

RESULTS

Longer GAD duration predicted less anxiety reduction in CBT and ND relative to AR. These effects were pronounced in the later phase of treatment, suggesting benefits of focused relaxation practice for clients with longer duration. Higher depression predicted better response to CBT than AR and ND. The moderation effects were also more noticeable in the later phase. In multilevel analyses, a similar moderation pattern held at 1-year follow-up on clinician-rated measures.

CONCLUSION

GAD clients with long-standing symptoms may benefit more from repeatedly practicing fewer skills than learning multiple skills. On the other hand, clients with comorbid depression may respond better to CBT than AR, perhaps because CBT includes cognitive interventions that can generalize to depression. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Psychological and pharmacological treatments for generalized anxiety disorder (GAD): a meta-analysis of randomized controlled trials

The purpose of this meta-analysis was to provide updated pooled effect sizes of evidence-based psychotherapies and medications for generalized anxiety disorder (GAD) and to investigate potential moderators of outcomes. Seventy-nine randomized controlled trials (RCT) including 11,002 participants with a diagnosis of GAD were included in a meta-analysis that tested the efficacy of psychotherapies or medications for GAD. Psychotherapy showed a medium to large effect size (g = 0.76) and medication showed a small effect size (g = 0.38) on GAD outcomes. Psychotherapy also showed a medium effect on depression outcomes (g = 0.64) as did medications (g = 0.59). Younger age was associated with a larger effect size for psychotherapy (p < 0.05). There was evidence of publication bias in psychotherapy studies. This analysis found a medium to large effect for empirically supported psychotherapy interventions on GAD outcomes and a small effect for medications on GAD outcomes. Both groups showed a medium effect on depression outcomes. Because medication studies had more placebo control conditions than inactive conditions compared to psychotherapy studies, effect sizes between the domains should not be compared directly. Patient age should be further investigated as a potential moderator in psychotherapy outcomes in GAD.

Activation vs. Experiential Avoidance as a Transdiagnostic Condition of Emotional Distress: An Empirical Study

Background: From a contextual transdiagnostic approach, this study focuses on the importance of the processes of Experiential Avoidance and Activation in explaining and treating psychological problems. There exists widespread empirical evidence to suggest that the response pattern known as Experiential Avoidance, a general unwillingness to remain in contact with particular private experiences through the use of maladaptive avoidance strategies, acts as a functional dimension in various psychological problems. Activation, that is, maintaining contact with experiences/conditions of life and consequently with associated sources of reward, is a condition present in most therapeutic processes. Although a great deal of research has analyzed the relationship of the value of reward with the etiology and maintenance of psychological problems, Activation, as a transdiagnostic factor, has been studied less. The aim of this paper is to carry out an empirical study of the relationship between Activation, EA and emotional state and analyze the capacity of these two conditions to discriminate the intensity and symptomatology type in subjects with emotional distress. Methods: The Hospital Anxiety and Depression Scale (HADS), Environmental Reward Observation Scale (EROS) and Behavioral Activation for Depression Scale (BADS) were completed by 240 health center users. Results: Of the participants, 55% showed clinically relevant emotional distress. All cases of depression showed clinical anxiety. To discriminate between subjects without (n = 109) and with emotional distress (n = 131), analyses of the ROC curves and logistic regression analysis identified the BADS-Avoidance/Rumination followed by the EROS. To discriminate between subjects with anxiety but without depression (n = 61) and with anxiety and depression (n = 70), the most efficient scales were EROS followed by BADS-Social Impairment. Conclusion: It was shown that people with no emotional complaints maintained greater contact with life experiences and with environmental sources of reward than those with emotional distress. Response patterns showing Experiential Avoidance and a reduction in Activation responses were associated with clinical distress. A reduction in Activation was the condition which distinguished those people with the greatest distress and also the greatest comorbidity of symptoms of depression and anxiety. These data support the transdiagnostic nature of Activation and suggest greater attention should be paid to this concept.

Relaxation-induced anxiety: Effects of peak and trajectories of change on treatment outcome for generalized anxiety disorder

OBJECTIVE

Evidence is mixed regarding whether relaxation-induced anxiety (RIA) impedes relaxation training (RT) efficacy. Unlike past studies that averaged RIA across sessions, we examined peak RIA, change in RIA level across sessions, and timing of peak RIA with outcome.

METHOD

This was a secondary analysis of Borkovec, Newman, Pincus, and Lytle [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. doi: 10.1037/0022-006X.70.2.288 ]. Forty-one GAD participants were assigned randomly to CBT (n = 22) or BT (n = 19). Both treatments contained RT and RIA ratings within 13/14 sessions. Analyses used generalized additive mixed models (GAMMs), which accounted for longitudinal nonindependence and examined nonlinear trajectories of change.

RESULTS

All participants improved significantly regardless of RIA. "Change trajectory of RIA level did not predict outcome". Instead, lower peak RIA predicted fewer GAD symptoms at post-treatment and greater likelihood to continue to improve during follow-up. Also, timing of peak was important. Whereas lower peak early in therapy did not predict outcome, lower peak during the last third of treatment did. Peak RIA's effect was neither accounted for by baseline symptom severity, treatment condition, comorbidity, nor by preceding or concurrent anxiety symptom change.

CONCLUSIONS

People with consistently low peak RIA and/or who fully habituate to RIA by the end of therapy respond optimally to relaxation-based treatments.

A Pilot Study of Emotion Regulation Therapy for Generalized Anxiety and Depression: Findings From a Diverse Sample of Young Adults

Emotion regulation therapy (ERT) for generalized anxiety disorder (GAD) and accompanying major depressive disorder (MDD) is a theoretically derived, evidence-based treatment that integrates principles from traditional and contemporary cognitive-behavioral and experiential approaches with basic and translational findings from affect science to offer a blueprint for improving intervention by focusing on the motivational responses and corresponding self-referential regulatory characteristics. Preliminary evidence supports the efficacy of a 20-session version of ERT. However, previous trials of ERT and other traditional and contemporary cognitive-behavioral therapies have often utilized relatively homogeneous samples. Various contextual and demographic factors may be associated with challenges that increase risk for negative mental and social outcomes for young adults ages 18-29, particularly for individuals from diverse backgrounds. The aim of this pilot study was to examine the effectiveness of a briefer 16-session version of ERT in a racially and ethnically diverse sample of young adults. Participants (N = 31) were enrolled at an urban-based, commuter college who consented to treatment for anxiety, worry, or depression at an on-campus counseling center. Open-trial results demonstrate strong ameliorative changes in worry, rumination, self-reported and clinician-rated GAD and MDD severity, social disability, quality of life, attentional flexibility, decentering/distancing, reappraisal, trait mindfulness, and negative emotionality from pre- to posttreatment. These gains were maintained throughout a 3- and 9-month follow-up. These findings provide preliminary evidence for the efficacy of ERT in treating a racially and ethnically heterogeneous population. Further, this study highlights comparable effectiveness of a briefer 16-session version of ERT.

A randomized controlled trial of emotion regulation therapy for generalized anxiety disorder with and without co-occurring depression

OBJECTIVE

Generalized anxiety disorder (GAD) and major depression (MDD), especially when they co-occur, are associated with suboptimal treatment response. One common feature of these disorders is negative self-referential processing (NSRP; i.e., worry, rumination), which worsens treatment outcome. Emotion Regulation Therapy (ERT) integrates principles from affect science with traditional and contemporary cognitive-behavioral treatments to identify and modify the functional nature of NSRP by targeting motivational and regulatory mechanisms, as well as behavioral consequences.

METHOD

Building on encouraging open trial findings, 53 patients with a primary diagnosis of GAD (43% with comorbid MDD) were randomly assigned to immediate treatment with ERT (n = 28) or a modified attention control condition (MAC, n = 25).

RESULTS

ERT patients, as compared with MAC patients, evidenced statistically and clinically meaningful improvement on clinical indicators of GAD and MDD, worry, rumination, comorbid disorder severity, functional impairment, quality of life, as well as hypothesized mechanisms reflecting mindful attentional, metacognitive, and overall emotion regulation, which all demonstrated mediation of primary outcomes. This superiority of ERT exceeded medium effect sizes with most outcomes surpassing conventions for a large effect. Treatment effects were maintained for nine months following the end of acute treatment. Overall, ERT resulted in high rates of high endstate functioning for both GAD and MDD that were maintained into the follow-up period.

CONCLUSIONS

Findings provide encouraging support for the efficacy and hypothesized mechanisms underlying ERT and point to fruitful directions for improving our understanding and treatment of complex clinical conditions such as GAD with co-occurring MDD. (PsycINFO Database Record

Clinical characteristics of generalized anxiety disorder: older vs. young adults

BACKGROUND

Generalized anxiety disorder (GAD) is one of the most common anxiety disorders in older people. Although GAD in older adults seems to differ in many aspects like clinical presentation, severity and treatment response, there is a paucity of comparative research.

AIMS

The aim of the study is to compare the clinical presentation of GAD between older and young adults.

METHODS

One hundred and two non-demented older patients (age ≥65) and 64 young patients (age <45) who were diagnosed with GAD according to the DSM-IV-TR criteria were included to the study. Socio-demographic Data Form, the Structured Clinical Interview for DSM Disorders-1 (SCID-1), the Questionnaire for the Suggested Behavioral Criteria of GAD for DSM-5, the Hamilton Depression Scale (HAM-D), the Generalized Anxiety Disorder Severity Scale (GADSS) and the Sheehan Disability Scale (SDS) were applied to both groups.

RESULTS AND CONCLUSIONS

Older GAD patients had more disturbances of sleep, less reassurance seeking behaviors, higher rates of depression and higher depression severity when compared to the young patients. Although older people seemed to have a lower severity of GAD, they had higher disability due to worries. Older patients worried more about their own health and family well-being, whereas young patients worried more about future and other's health.

Distinct Functional Connectivities Predict Clinical Response with Emotion Regulation Therapy

Despite the success of available medical and psychosocial treatments, a sizable subgroup of individuals with commonly co-occurring disorders, generalized anxiety disorder (GAD) and major depressive disorder (MDD), fail to make sufficient treatment gains thereby prolonging their deficits in life functioning and satisfaction. Clinically, these patients often display temperamental features reflecting heightened sensitivity to underlying motivational systems related to threat/safety and reward/loss (e.g., somatic anxiety) as well as inordinate negative self-referential processing (e.g., worry, rumination). This profile may reflect disruption in two important neural networks associated with emotional/motivational salience (e.g., salience network) and self-referentiality (e.g., default network, DN). Emotion Regulation Therapy (ERT) was developed to target this hypothesized profile and its neurobehavioral markers. In the present study, 22 GAD patients (with and without MDD) completed resting state MRI scans before receiving 16 sessions of ERT. To test study these hypotheses, we examined the associations between baseline patterns of intrinsic functional connectivity (iFC) of the insula and of hubs within the DN (anterior and dorsal medial prefrontal cortex [MPFC] and posterior cingulate cortex [PCC]) and treatment-related changes in worry, somatic anxiety symptoms and decentering. Results suggest that greater treatment linked reductions in worry were associated with iFC clusters in both the insular and parietal cortices. Greater treatment linked gains in decentering, a metacognitive process that involves the capacity to observe items that arise in the mind with healthy psychological distance that is targeted by ERT, was associated with iFC clusters in the anterior and posterior DN. The current study adds to the growing body of research implicating disruptions in the default and salience networks as promising targets of treatment for GAD with and without co-occurring MDD.

Emotion Regulation Therapy: A Mechanism-Targeted Treatment for Disorders of Distress

"Distress disorders," which include generalized anxiety disorder and major depression are often highly comorbid with each other and appear to be characterized by common temperamental features that reflect heightened sensitivity to underlying motivational systems related to threat/safety and reward/loss. Further, individuals with distress disorders tend to utilize self-referential processes (e.g., worry, rumination, self-criticism) in a maladaptive attempt to respond to motivationally relevant distress, often resulting in suboptimal contextual learning. Despite the success of cognitive behavioral therapies for emotional disorders, a sizable subgroup of patients with distress disorders fail to evidence adequate treatment response. Emotion Regulation Therapy (ERT) is a theoretically derived, evidence based, treatment that integrates principles (e.g., skills training, exposure) from traditional and contemporary therapies with findings from basic and translational affective science to offer a framework for improving intervention by focusing on the motivational responses and corresponding regulatory characteristics of individuals with high levels of chronic distress. Open and randomized controlled trials have demonstrated preliminary support for the utility of ERT as reflected by strong effect sizes comparable to and exceeding established intervention approaches. In addition, pilot findings support the role of underlying proposed mechanisms in this efficacious response. This article presents the functional model associated with ERT and describes the proposed mechanisms of the treatment. Additionally, a clinical case is presented, allowing the reader to gain a greater applied understanding of the different components of the ERT model and treatment.

The Neurobiological Mechanisms of Generalized Anxiety Disorder and Chronic Stress

Two classification systems are now at the forefront of clinical psychiatric research: (1) Diagnostic and Statistical Manual, Fifth Edition and (2) the National Institutes of Mental Health Research Domain Criteria. Herein, we propose that these two classification systems are complementary rather than mutually exclusive, and when combined provide important information for understanding aspects of the pathophysiology related to Generalized Anxiety Disorder (GAD). The neurobiological literature for GAD and one relevant research domain criteria component, sustained threat, are reviewed from multiple units of analysis (genetic, neuroimaging, neuroendocrine, and psychophysiological). It is hypothesized that generating a comprehensive, biologically based understanding of the relationship between GAD, sustained threat, and the measureable units of analysis will provide information critical to design the most effective treatments.

Prevalence, correlates, comorbidity and severity of generalized anxiety disorder in Singapore

Despite its pervasiveness and associated impairment, generalized anxiety disorder (GAD) remains a poorly recognized disorder. Furthermore, given that GAD has been relatively understudied in Asia, the current study examined the prevalence, correlates and co-morbid conditions of this disorder in a multi-ethnic population of Singapore. Data was utilized from the Singapore Mental Health Study (SMHS), a cross-sectional epidemiological survey conducted among the adult population (n=6616) aged 18 years and above. The Composite International Diagnostic Interview version 3.0 (CIDI v3.0) was used to assess co-morbidity as well as the life-time and 12-month prevalence of disorders. Functional impairment and treatment-seeking behavior were also assessed. The life-time (0.9%) and 12-month (0.4%) prevalence estimates in the current study were found to be lower than those reported in Western populations but comparable to the prevalence estimates found in Asian countries. The relatively lower prevalence rate of GAD in this study suggests the possible role of culture in reporting and manifestation of anxiety symptomatology. The failure of a substantial proportion of individuals to seek treatment despite self-reported impairment was also identified as an area of concern.

Within-subject covariation between depression- and anxiety-related affect

Studies find a strong positive relationship between the affective components of anxiety and depression. However, most research thus far has examined the between-person correlations among these constructs, while ignoring how changes in these two types of affect covary over time within a person. Within-person correlations could differ meaningfully from how anxiety- and depression-related affect relate across individuals. Further, individuals may differ in terms of how highly these constructs covary over time. The current study aimed to (1) compare between- and within-person correlations between anxious and depressive affect, (2) examine lagged effects between anxious and depressive affect over time, (3) test whether individuals differ in their within-person correlations between these two types of affect, and (4) examine whether the mean level of affective intensity moderated these individual differences. These questions were explored using college undergraduates (N = 50) who rated their depression- and anxiety- related affect six times a day for two weeks. A higher average correlation was observed between anxious and depressive affect in between-person compared to within-person analyses. Significant bidirectional lagged effects were observed between these constructs. Individuals with higher average levels of anxious affect experienced stronger within-person correlations between anxious and depressive affect.

Reductions in the diurnal rigidity of anxiety predict treatment outcome in cognitive behavioral therapy for generalized anxiety disorder

Generalized anxiety disorder (GAD) is a chronic and disabling disorder which is characterized by worrisome mentation about future outcomes. Because the evocative stimuli in GAD are largely internally derived, the feared outcomes contained in worry episodes can be invoked--and responded to--regardless of external context. We hypothesized that individuals with GAD would be entrained to internally-regulated, fixed patterns of anxiety on a day-to-day basis and that successful therapeutic intervention would serve to mitigate this entrainment. Thus, the present study examined the constructs of flexibility and rigidity as they apply to the daily fluctuation of anxious symptoms in individuals with GAD. We aimed to demonstrate that an apparently variable system can be conceptualized as rigid when the variability maps onto stable and predictable periodic oscillations. Sixty-nine individuals completed cognitive-behavioral treatment for GAD. Average age was 36.62 years (SD = 11.56), and participants were mostly Caucasian (89.5%) and female (68.4%). Daily-diary data indicating level of anxiety on a 0 to 100-point scale and collected four times per day were subjected to spectral analysis in order to determine the spectral power attributable to daily oscillations--which was related to the degree of rigidity in daily anxiety. Diurnal rigidity decreased throughout therapy and the degree to which rigidity was reduced significantly predicted reliable change at post-treatment. Thus, symptom rigidity can be conceptualized as stable periodic fluctuation and is discernible from other metrics of volatility in repeated measures data. Moreover, diurnal rigidity is significantly reduced during treatment, facilitating flexible responding to environmental demands.

The Feasibility, Acceptability, and Efficacy of Delivering Internet-Based Self-Help and Guided Self-Help Interventions for Generalized Anxiety Disorder to Indian University Students: Design of a Randomized Controlled Trial

BACKGROUND

Generalized anxiety disorder (GAD) is one of the most common mental disorders among university students; however, many students go untreated due to treatment costs, stigma concerns, and limited access to trained mental health professionals. These barriers are heightened in universities in India, where there are scant mental health care services and severe stigma surrounding help seeking.

OBJECTIVE

To evaluate the feasibility, acceptability, and efficacy of Internet-based, or "online," cognitive behavioral therapy (CBT)-based unguided and guided self-help interventions (using the programs GAD Online and Lantern, respectively) to reduce GAD symptoms in students with clinical and subthreshold GAD and, ultimately, reduce the prevalence and incidence of GAD among the student population.

METHODS

Students will be recruited via 3 colleges in Hyderabad, India, and referred for a campus-wide online screening. Self-report data will be collected entirely online. A total of 300 qualifying students will be randomized in a 1:1:1 ratio to receive GAD Online, Lantern, or to be in a wait-list control condition, stratified by clinical and subthreshold GAD symptomatology. Students will complete a postintervention assessment after 3 months and a follow-up assessment 6 months later, at which point students in the wait-list control condition will receive one of the programs. The primary outcome is GAD symptom severity at 3 months postintervention. Secondary outcomes include GAD caseness at 9 months, other anxiety and depression symptoms, self-efficacy, and functional measures (eg, sleep, social functioning) at 3 and 9 months, respectively. Primary analyses will be differences between each of the intervention groups and the wait-list control group, analyzed on an intention-to-treat (ITT) basis using mixed-design ANOVA.

RESULTS

The study commenced in February 2015. The sample was recruited over a 3-week period at each college. The trial is expected to end in December 2015.

CONCLUSIONS

This trial will be the first to evaluate the use of Internet-based CBT programs compared with a wait-list control group for the treatment of GAD among students in Indian universities. If effective, these programs have the potential to reduce the mental health care treatment gap by providing readily accessible, private, and cost-effective evidence-based care to students with GAD who do not currently receive the treatment they need.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02410265 http://clinicaltrials.gov/ct2/show/NCT02410265 (Archived by WebCite at http://www.webcitation.org/6ddqH6Rbt).

The relationship between depression and generalized anxiety during intensive psychological and pharmacological treatment

BACKGROUND

In the present study we examined the relationship between depressive symptoms and generalized anxiety symptoms during intensive cognitive-behavioral and pharmacological treatment.

METHOD

Individuals (n = 157) with major depressive disorder (MDD; n = 83), generalized anxiety disorder (GAD; n = 29) and their combination (n = 45) who attended an intensive partial hospital treatment program, completed daily self-report measures of depression and generalized anxiety. Treatment included empirically-based cognitive-behavioral interventions in both individual and group format, as well as pharmacotherapy.

RESULTS

Multilevel linear modeling indicated that for all diagnostic groups, changes in depressive symptoms led to changes in generalized anxiety symptoms to a greater extent than vice versa during treatment. Moreover, changes in depressive symptoms fully mediated changes in generalized anxiety symptoms, whereas changes in generalized anxiety symptoms only partially mediated the changes in depressive symptoms.

LIMITATIONS

Partial hospital setting.

CONCLUSIONS

Our results suggest that depressive symptoms may play a prominent role in the process of change in both MDD and GAD. This has implications for the classification of GAD as well as for choosing early treatment targets for individuals with comorbid MDD and GAD.

AN OPEN TRIAL OF EMOTION REGULATION THERAPY FOR GENERALIZED ANXIETY DISORDER AND COOCCURRING DEPRESSION

BACKGROUND

Although CBT is efficacious for a wide variety of psychiatric conditions, relatively fewer GAD patients achieve high endstate functioning as compared to patients receiving CBTs for other disorders. Moreover, GAD trials that utilized patient samples without prominent depression have tended to report that effect sizes for depressive outcomes were small or diminished to pretreatment levels in the follow-up period. Emotion regulation therapy (ERT) integrates principles from traditional and contemporary cognitive behavioral treatments with basic and translational findings from affect science to offer a blueprint for improving intervention by focusing on motivational, regulatory, and contextual learning mechanisms.

METHOD

The purpose of this investigation was to provide initial support for the efficacy of ERT in an open trial of patients with GAD and cooccurring depressive symptoms. Twenty-one patients received a 20-session version of ERT delivered in weekly individual sessions. Standardized clinician ratings and self-report measures were assessed at pre-, mid-, and posttreatment as well as at three- and nine-month follow-ups. Intent-to-treat analyzes were utilized.

RESULTS

GAD patients, half with comorbid major depression, evidenced statistically, and clinically meaningful improvements in symptom severity, impairment, quality of life, and in model-related outcomes including emotional/motivational intensity, mindful attending/acceptance, decentering, and cognitive reappraisal. Patients maintained gains across the three and nine month follow-up periods.

CONCLUSIONS

These findings, although preliminary, provide additional evidence for the role of emotion dysregulation in the onset, maintenance, and now treatment of conditions such as GAD and cooccurring depressive symptoms.

Classification models for subthreshold generalized anxiety disorder in a college population: Implications for prevention

Generalized anxiety disorder (GAD) is one of the most common psychiatric disorders on college campuses and often goes unidentified and untreated. We propose a combined prevention and treatment model composed of evidence-based self-help (SH) and guided self-help (GSH) interventions to address this issue. To inform the development of this stepped-care model of intervention delivery, we evaluated results from a population-based anxiety screening of college students. A primary model was developed to illustrate how increasing levels of symptomatology could be linked to prevention/treatment interventions. We used screening data to propose four models of classification for populations at risk for GAD. We then explored the cost considerations of implementing this prevention/treatment stepped-care model. Among 2489 college students (mean age 19.1 years; 67% female), 8.0% (198/2489) met DSM-5 clinical criteria for GAD, in line with expected clinical rates for this population. At-risk Model 1 (subthreshold, but considerable symptoms of anxiety) identified 13.7% of students as potentially at risk for developing GAD. Model 2 (subthreshold, but high GAD symptom severity) identified 13.7%. Model 3 (subthreshold, but symptoms were distressing) identified 12.3%. Model 4 (subthreshold, but considerable worry) identified 17.4%. There was little overlap among these models, with a combined at-risk population of 39.4%. The efficiency of these models in identifying those truly at risk and the cost and efficacy of preventive interventions will determine if prevention is viable. Using Model 1 data and conservative cost estimates, we found that a preventive intervention effect size of even 0.2 could make a prevention/treatment model more cost-effective than existing models of "wait-and-treat."

Prognostic subgroups for remission and response in the Coordinated Anxiety Learning and Management (CALM) trial

OBJECTIVE

Most patients with anxiety disorders receive treatment in primary care settings. Limited moderator data are available to inform clinicians of likely prognostic outcomes for individual patients. We identify baseline characteristics associated with outcome in adults seeking treatment for anxiety disorders.

METHOD

We conducted an exploratory moderator analysis from the Coordinated Anxiety Learning and Management (CALM) trial. In the CALM trial, 1,004 adults who met DSM-IV criteria for generalized anxiety disorder (GAD), panic disorder, social anxiety disorder, and/or posttraumatic stress disorder (PTSD) were randomized to usual care (UC) or a collaborative care intervention (ITV) of cognitive-behavioral therapy and/or pharmacotherapy between June 2006 and April 2008. Logistic regression was used to examine baseline characteristics associated with remission and response overall and by treatment condition. Receiver operating curve (ROC) analyses identified subgroups associated with similar likelihood of response and remission of global anxiety symptoms. Remission was defined as score < 6 on the 12-item Brief Symptom Inventory (BSI-12) anxiety and somatization subscales. Response was defined as at least 50% reduction on BSI-12, or meeting remission criteria.

RESULTS

Randomization to ITV over UC was often the strongest predictor of outcome. Several baseline patient characteristics were associated with poor treatment outcome including comorbid depression, increased severity of underlying anxiety disorder(s) (P < .001), low socioeconomic status (perceived [P < .001] and actual [P < .05]), and limited social support (P < .001). Patient characteristics associated with particular benefit from ITV were being female (P < .05), increased depression (P < .01)/GAD severity (P < .05), and low socioeconomic status (P < .05). ROC analysis demonstrated prognostic subgroups with large differences in response likelihood.

CONCLUSIONS

Further research should focus on the effectiveness of implementing the ITV intervention of CALM in community treatment centers where patients typically are of low socioeconomic status and may particularly benefit from ITV.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00347269.

Blockade of the GLT-1 Transporter in the Central Nucleus of the Amygdala Induces both Anxiety and Depressive-Like Symptoms

Depression has been associated with abnormalities in glutamatergic neurotransmission and decreased astrocyte number in limbic areas. We previously demonstrated that global and prefrontal cortical blockade of the astrocytic glutamate transporter (GLT-1) induces anhedonia and c-Fos expression in areas that regulate anxiety, including the central amygdala (CEA). Given the role of the amygdala in anxiety and the high degree of comorbidity between anxiety and depression, we hypothesized that GLT-1 blockade in the CEA would induce symptoms of anhedonia and anxiety in rats. We microinjected the GLT-1 inhibitor, dihydrokainic acid (DHK), into the CEA and examined effects on intracranial self-stimulation (ICSS) as an index of hedonic state, and on behavior in two anxiety paradigms, elevated plus maze (EPM) and fear conditioning. At lower doses, intra-CEA DHK produced modest increases in ICSS responding (T0). Higher doses resulted in complete cessation of responding for 15 min, suggesting an anhedonic or depressive-like effect. Intra-CEA DHK also increased anxiety-like behavior such that percent time in the open arms and total entries were decreased in the EPM and acquisition of freezing behavior to the tone was increased in a fear-conditioning paradigm. These effects did not appear to be explained by non-specific changes in activity, because effects on fear conditioning were assessed in a drug-free state, and a separate activity test showed no significant effects of intra-CEA DHK on locomotion. Taken together, these studies suggest that blockade of GLT-1 in the CEA is sufficient to induce both anhedonia and anxiety and therefore that a lack of glutamate uptake resulting from glial deficits may contribute to the comorbidity of depression and anxiety.

Rethinking the role of worry in generalized anxiety disorder: evidence supporting a model of emotional contrast avoidance

The Contrast Avoidance model (Newman & Llera, 2011) proposes that individuals with generalized anxiety disorder (GAD) are hypersensitive to sharp upward shifts in negative emotion that typically accompany negative events, and use worry to maintain sustained intrapersonal negativity in an attempt to avoid these shifts. Although research shows that worry increases negative emotionality and mutes further emotional reactivity to a stressor when compared to the worry period (e.g., Llera & Newman, 2010), no study has tracked changes in negative emotionality from baseline to worry inductions followed by a range of emotional exposures. Further, no study has yet assessed participants' subjective appraisals of prior worry on helping to cope with such exposures. The present study tested the main tenets of the Contrast Avoidance model by randomly assigning participants with GAD (n=48) and nonanxious controls (n=47) to experience worry, relaxation, and neutral inductions prior to sequential exposure to fearful, sad, and humorous film clips. Both physiological (nonspecific skin conductance responses [NS-SCRs]) and self-reported emotional changes were observed. Results indicated that worry boosted negative emotionality from baseline, which was sustained across negative exposures, whereas low negative emotionality during relaxation and neutral inductions allowed for sharp increases in response to exposures. Furthermore, GAD participants found worry to be more helpful than other conditions in coping with exposures, whereas control participants reported the opposite pattern. Results provide preliminary support for the Contrast Avoidance model. This suggests that treatment should focus on underlying avoidance patterns before attempting to reduce worry behavior.

Economic and humanistic burden of illness in generalized anxiety disorder: an analysis of patient survey data in Europe

BACKGROUND

Whilst studies suggest that generalized anxiety disorder (GAD) represents a considerable health care burden in Europe, there is a paucity of published evidence. This study investigated the burden of illness associated with GAD across five European countries (France, Germany, Italy, Spain, and the UK).

METHODS

Information from the 2008 European National Health and Wellness Survey database was analyzed. Bivariate, multivariate, and cost analyses were used to compare patients with GAD and propensity-matched controls.

RESULTS

Compared with non-GAD controls, patients with GAD had more comorbidities and were more likely to smoke but less likely to be employed, use alcohol, or take exercise. They also had significantly worse health-related quality of life, and significantly greater work impairment and resource use, which increased as GAD severity increased. Within-country analyses demonstrated results similar to those for the five European countries overall, with the largest differences in resource use between patients with GAD and non-GAD controls documented in France and Germany. The average mean differences in direct costs were relatively small between the GAD groups and controls; however, indirect costs differed substantially. Costs were particularly high in Germany, mainly due to higher salaries leading to higher costs associated with absence from work. The limitation of this study was that the data were from a self-reported Internet survey, making them subject to reporting bias and possibly sample bias.

CONCLUSION

Across all five European countries, GAD had a significant impact on work impairment, resource use, and economic costs, representing a considerable individual and financial burden that increased with severity of disease. These data may help us to understand better the burden and costs associated with GAD.

Effect of Comorbid Depression on Cognitive Behavioural Group Therapy for Social Anxiety Disorder

Many individuals seeking treatment for social anxiety disorder (SAD) also meet criteria for a comorbid depressive disorder. Little is known, however, about how a comorbid depressive disorder affects social anxiety treatment. This study examined 61 participants with SAD and 72 with SAD and a comorbid depressive disorder (SAD+D) before and after 12 weeks of cognitive behavioural group therapy (CBGT) for social anxiety. Although patients with SAD+D reported more severe symptoms of social anxiety and depression at pretreatment, treatment was similarly effective for individuals with SAD and SAD+D. However, individuals with SAD+D continued to report higher symptom severity at post-treatment. Interestingly, CBGT for social anxiety also led to improvements in depressive symptoms despite the fact that depression was not targeted during treatment. Improvement in social anxiety symptoms predicted 26.8% of the variance in improvement in depressive symptoms. Results suggest that depressive symptoms need not be in remission for individuals to benefit from CBGT for social anxiety. However, more than 12 sessions of CBGT may be beneficial for individuals with comorbid depression.

Clinical experiences in conducting cognitive-behavioral therapy for social phobia

Several authors have identified a disconnect between psychotherapy research, including research on cognitive behavioral therapy (CBT), and real-world psychotherapy practice. This disconnect has several negative consequences, potentially including less-than-optimal practice standards as well as a lack of input from practicing psychotherapists on how research can be improved and made more relevant in their day-to-day clinical work. As part of an ongoing effort to engage practicing psychotherapists in a feedback loop with psychotherapy researchers, this study reports the results of a survey of CBT therapists who have used CBT in the treatment of social phobia (SP). The survey was designed primarily to document how often certain potential problems, identified by expert researchers and CBT manuals, actually act as barriers to successful treatment when CBT is employed in nonresearch environments. The participants were 276 psychotherapists responding to email, online, and print advertisements completing the online survey. Participants varied considerably in psychotherapy experience, work environment, experience in using CBT for SP, and in some ways varied in their usual CBT techniques when treating SP. Among the most prominent barriers identified by many of the participants were patient motivation, comorbidity, logistical problems (especially with exposures), patient resistance, and severity and chronicity of SP symptoms. These findings may be useful for psychotherapy researchers as areas for potential study. The results may also suggest topics requiring clinical guidelines, innovations within CBT, and dissemination of successful techniques to address the barriers identified here.

Clinical experiences in conducting empirically supported treatments for generalized anxiety disorder

Knowledge of the efficacy of cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD) predominantly derives from randomized controlled trials (RCTs). However, there may be unique or complex issues encountered in practice, but not necessarily in the context of a controlled clinical trial. Therefore, launching a systematic dialogue between researcher and practicing clinician can be instrumental in augmenting evidence-based therapies through identification of variables that promote and interfere with clinical effectiveness. Through an initiative sponsored by the American Psychological Association's Divisions 12 (Society for Clinical Psychology) and 29 (Psychotherapy), this study aimed to examine clinical experiences conducting CBT for GAD. The participants were 260 psychotherapists who completed an online survey on assessment and therapeutic intervention utilization and their experience of factors that limit successful GAD treatment and symptom reduction. The majority of respondents reported 20 years or less experience using ESTs for GAD, typically treating clients in outpatient clinics, treatment centers, and private practice. Some of the most commonly used interventions address clients' maladaptive cognitions and elevated anxiety and muscle tension typical of GAD. Approximately one half of respondents reported incorporating integrative techniques into treatment. Factors perceived as limiting effective GAD treatment included severity and chronicity of GAD, presence of comorbid conditions, stressful home and work environments, client motivation and resistance to treatment, and issues encountered when executing therapy techniques. This study provides researchers with clinically derived directions for future empirical investigation into enhancing efficacy of GAD treatment.

Internet cognitive behavioural therapy for mixed anxiety and depression: a randomized controlled trial and evidence of effectiveness in primary care

BACKGROUND

Major depressive disorder (MDD) and generalized anxiety disorder (GAD) have the highest co-morbidity rates within the internalizing disorders cluster, yet no Internet-based cognitive behavioural therapy (iCBT) programme exists for their combined treatment.

METHOD

We designed a six-lesson therapist-assisted iCBT programme for mixed anxiety and depression. Study 1 was a randomized controlled trial (RCT) comparing the iCBT programme (n = 46) versus wait-list control (WLC; n = 53) for patients diagnosed by structured clinical interview with MDD, GAD or co-morbid GAD/MDD. Primary outcome measures were the Patient Health Questionnaire nine-item scale (depression), Generalized Anxiety Disorder seven-item scale (generalized anxiety), Kessler 10-item Psychological Distress scale (distress) and 12-item World Health Organization Disability Assessment Schedule II (disability). The iCBT group was followed up at 3 months post-treatment. In study 2, we investigated the adherence to, and efficacy of the same programme in a primary care setting, where patients (n = 136) completed the programme under the supervision of primary care clinicians.

RESULTS

The RCT showed that the iCBT programme was more effective than WLC, with large within- and between-groups effect sizes found (>0.8). Adherence was also high (89%), and gains were maintained at 3-month follow-up. In study 2 in primary care, adherence to the iCBT programme was low (41%), yet effect sizes were large (>0.8). Of the non-completers, 30% experienced benefit.

CONCLUSIONS

Together, the results show that iCBT is effective and adherence is high in research settings, but there is a problem of adherence when translated into the 'real world'. Future efforts need to be placed on developing improved adherence to iCBT in primary care settings.

The theory-practice gap in cognitive-behavior therapy

This special series is devoted to understanding the theory-practice gap in cognitive-behavior therapy (CBT). Although CBT enjoys considerable empirical support, and is widely recognized as an efficacious approach to a diversity of psychiatric disorders and includes many different forms of treatment, it is unclear whether clinicians are familiar with the underlying theories of the treatments they are practicing. Moreover, it is unclear to what degree an understanding of the theory is necessary for effective practice. Gaining clarity on the role of understanding underlying theory and identifying potential disparities between theory and practice may have implications for the way graduate training programs are structured and current professionals approach continuing education. A brief exploration of these implications will be offered by introducing issues related to the scientist-practitioner model and dissemination of efficacious treatments, in addition to an outline of potential advantages and disadvantages of knowing underlying theory. This special series will then feature several major approaches to treatment wherein the role of theory and practice are discussed.

Worry and generalized anxiety disorder: a review and theoretical synthesis of evidence on nature, etiology, mechanisms, and treatment

Generalized anxiety disorder (GAD) is associated with substantial personal and societal cost yet is the least successfully treated of the anxiety disorders. In this review, research on clinical features, boundary issues, and naturalistic course, as well as risk factors and maintaining mechanisms (cognitive, biological, neural, interpersonal, and developmental), are presented. A synthesis of these data points to a central role of emotional hyperreactivity, sensitivity to contrasting emotions, and dysfunctional attempts to cope with strong emotional shifts via worry. Consistent with the Contrast Avoidance model, evidence shows that worry evokes and sustains negative affect, thereby precluding sharp increases in negative emotion. We also review current treatment paradigms and suggest how the Contrast Avoidance model may help to target key fears and avoidance tendencies that serve to maintain pathology in GAD.

A randomized controlled trial of ecological momentary intervention plus brief group therapy for generalized anxiety disorder

Momentary intervention has been proposed as a cost-effective, generalizable, and ecologically valid method to increase the efficiency of face-to-face cognitive-behavioral therapy (CBT). The purpose of the current pilot study was to evaluate the efficacy of a six-session palmtop computer-assisted Group CBT for generalized anxiety disorder (GAD) (CAGT6) in comparison with a six-session Group CBT for GAD without the computer (CBGT6) and typical (12 session) Group CBT for GAD (CBGT12) in a randomized controlled trial. Thirty-four individuals with a primary diagnosis of GAD were randomized to one of the three conditions and completed measures of GAD and anxiety before therapy, after therapy, and at 6-, and 12-month follow-ups. Results indicated that CAGT6 was superior to CBGT6 at posttreatment, but not significantly different from CBGT12. At 6- and 12-month follow-ups, CAGT6 was neither significantly different from CBGT6, nor from CBGT12. Percentages of individuals achieving reliable change on two of the three GAD measures favored CAGT6 over CBGT6 at posttreatment, suggesting promise for the added value of the mobile technology.

What, Me Worry and Ruminate About DSM-5 and RDoC? The Importance of Targeting Negative Self-Referential Processing

Rumination, worry, and other forms of negative self-referential processing (NSRP) are familiar to everyone, as reflecting on the self is perhaps our most human characteristic. However, for a substantial subgroup of patients, NSRP arises in response to intense emotionality, worsening the clinical presentation, and diminishing the treatment response. The combination of emotionality and NSRP likely reflects an endophenotype of complicated and treatment refractory patients who fail to achieve a satisfactory treatment response in our trials and our clinics. An important next step is to personalize treatments by deliberately targeting NSRPs within established treatment protocols or in as yet novel treatments. Enriching treatments with mindfulness meditation is one possible avenue for personalized care of patients with this hypothesized endophenotype.