Cognitive Behavioral Treatment of Generalized Anxiety Disorder

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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)

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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.

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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

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Generalized Anxiety DisorderDiagnostic
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

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Core Patterns in GAD

• Uncontrollable worry
• Future orientation
• Negative cognitive biases
• Somatic arousal
• Role and task inefficiency
• Interpersonal aversiveness (unbalanced
  relationships)

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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

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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

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

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

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Meta-Analysis of CBT Gould et al., 2004Between
Groups
Effect Size (d)
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Specificity of Treatment (Siev Chambless,
2007, JCCP)

• GAD CT RT
• Panic Disorder CT gt RT
• Cognitive Therapy (CT) includes interoceptive
  exposure
• Relaxation Therapy (RT)

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Meta-Analyses of Effectiveness Studies (Within
ES) (Stewart Chambless, 2009, JCCP)
Effect Size (d)
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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

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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)

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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.

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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

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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)

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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

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Borkovec

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

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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)

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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)

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Intolerance of Uncertainty

• Motivates unnecessary worry-based planning
• What if X happens, could I cope by

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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

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Treatment ElementsBorkovec

• Awareness and self-monitoring
• Relaxation
• Cognitive therapy
• Imagery rehearsal of coping strategies
• (see Borkovec, 2006 for review)

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Treatment ElementsWells

• Case formulation
• Socialization to treatment
• Modifying negative beliefs about the
  uncontrollability of worry
• Modifying beliefs about the danger of worry
• Modifying positive beliefs about worry
• (Wells, 1999)

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Treatment ElementsDugas et al.

• Uncertainty recognition and behavioral exposure
• Re-evaluation of the usefulness of worry
• Problem-solving training
• Imaginal exposure
• (Dugas et al., 2003)

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Relaxation Strategies

• Progressive Relaxation (PR e.g., Bernstein
  Borkovec, 1973)
• Applied Relaxation (ARO st, 1987).
• AR does include exposure elements

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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

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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

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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

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Cognitive Restructuring

• Self monitoring
• Logical analysis
• Probability overestimations
• Overestimations of the degree of catastrophe
• Ability to cope

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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)

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Mindfulness

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

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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

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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

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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

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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

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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)

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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)

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New Directions

• Attentional training
• Mindfulness/emotional tolerance training
• Interoceptive exposure
• Integrative treatment

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GAD Interpersonal Roles

• Polarizing the relationship the worry partner
• Improving couples problem-solving

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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