Skip to main content

Advertisement

SpringerLink
Log in

Advances in Psychotherapy for Generalized Anxiety Disorder

  • ANXIETY DISORDERS (DJ STEIN, SECTION EDITOR)
  • Published:
Current Psychiatry Reports Aims and scope Submit manuscript

Abstract

Since the introduction of generalized anxiety disorder into the diagnostic system for psychiatric conditions, scientists have worked to develop effective treatments for the amelioration of chronic, excessive worry. In addition to traditional cognitive-behavioral therapy, more recent advances have focused on treatments targeting intolerance of uncertainty, meta-cognitions, emotion dysregulation, lack of acceptance of internal experiences, and emotional contrasts. This article reviews these therapeutic approaches and summarizes recent publications relevant to the psychological treatment of worry and generalized anxiety disorder.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of Importance

  1. American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders (3rd ed). Washington, DC 1980.

  2. Freud S. Anxiety. In J. Strachey (Ed. & Trans.), Introductory lectures on psychoanalysis 1966. pp. 487–511. New York: Norton. (Original work published 1920).

  3. Mennin DS, Heimberg RG, Turk CL. Clinical presentation and diagnostic features. In: Heimberg RG, Turk CL, Mennin DS, editors. Generalized anxiety disorder: Advances in research and practice. New York: Guilford; 2004. p. 3–28.

    Google Scholar 

  4. Borkovec TD, Alcaine O, Behar E. Avoidance theory of worry and generalized anxiety disorder. In: Heimberg RG, Turk CL, Mennin DS, editors. Generalized anxiety disorder: Advances in research and practice. New York: Guilford; 2004. p. 77–108.

    Google Scholar 

  5. American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author 2000.

  6. Behar E, Dobrow I, Hekler E, Mohlman J, Staples A. Current theoretical models of generalized anxiety disorder (GAD): conceptual review and treatment implications. Journal of Anxiety Disorders. 2009;23:1011–23.

    Article  PubMed  Google Scholar 

  7. Mowrer OH. On the dual nature of learning: A re-interpretation of “conditioning” and “problem-solving. Harv Educ Rev. 1947;17:102–48.

    Google Scholar 

  8. Borkovec TD, Inz J. The nature of worry in generalized anxiety disorder: a predominance of thought activity. Behav Res Ther. 1990;28:153–8.

    Article  PubMed  CAS  Google Scholar 

  9. Foa EB, Kozak MJ. Emotional processing of fear: exposure to corrective information. Psychol Bull. 1986;99:20–35.

    Article  PubMed  CAS  Google Scholar 

  10. Andreescu C, Gross JJ, Lenze E, Edelman KD, Snyder S, Tanase C, Aizenstein H. Altered cerebral blood flow patterns associated with pathologic worry in the elderly. Depression and Anxiety. 2011;28:202–9.

    Article  PubMed  Google Scholar 

  11. Stein MB, Simmons AN, Feinstein JS, Paulus MP. Increased amygdala and insula activation during emotion processing in anxiety-prone subjects. Am J Psychiatry. 2007;164:318–27.

    Article  PubMed  Google Scholar 

  12. Dugas MJ, Letarte H, Rheaume J, Freeston MH, Ladouceur R. Worry and problem solving: evidence of a specific relationship. Cogn Ther Res. 1995;19:109–20.

    Article  Google Scholar 

  13. Dugas MJ, Buhr K, Ladouceur R. The role of intolerance of uncertainty in etiology and maintenance. In: Heimberg RG, Turk CL, Mennin DS, editors. Generalized anxiety disorder: advances in research and practice. New York: Guilford; 2004. p. 143–63.

    Google Scholar 

  14. Dugas MJ, Gagnon F, Ladouceur R, Freeston MH. Generalized anxiety disorder: a preliminary test of a conceptual model. Behav Res Ther. 1998;36:215–26.

    Article  PubMed  CAS  Google Scholar 

  15. Freeston MH, Rheaume J, Letarte H, Dugas MJ, Ladouceur R. Why do people worry? Personal Individ Differ. 1994;17:791–802.

    Article  Google Scholar 

  16. • Gentes EL, & Ruscio AM. A meta-analysis of the relation of intolerance of uncertain to symptoms of generalized anxiety disorder, major depressive disorder, and obsessive-compulsive disorder. Clinical Psychology Review, 2011;31:923–933. This study presents a meta-analysis of the role of intolerance of uncertainty in GAD, major depressive disorder, and OCD. It clarifies recently unanswered questions about the specificity of the intolerance of uncertainty construct to GAD.

    Article  PubMed  Google Scholar 

  17. Wells A. A multi-dimensional measure of worry: development and preliminary validation of the anxious thoughts inventory. Anxiety Stress Coping. 1994;6:289–99.

    Article  Google Scholar 

  18. Wells A. A cognitive model of generalized anxiety disorder. Behaviour Modification. 1999;23:526–55.

    Article  CAS  Google Scholar 

  19. Wells A. A cognitive model of GAD: metacognitions and pathological worry. In: Heimberg RG, Turk CL, Mennin DS, editors. Generalized anxiety disorder: advances in research and practice. New York: Guilford; 2004. p. 164–86.

    Google Scholar 

  20. Wells A. The metacognitive model of GAD: assessment of meta-worry and relationship with DSM-IV generalized anxiety disorder. Cogn Ther Res. 2005;29:107–21.

    Article  Google Scholar 

  21. Mennin DS, Heimberg RG, Turk CL, Fresco DM. Applying an emotion regulation framework to integrative approaches to generalized anxiety disorder. Clin Psychol Sci Pract. 2002;9:85–90.

    Article  Google Scholar 

  22. Roemer L, Orsillo SM. Expanding our conceptualization of and treatment for generalized anxiety disorder: integrating mindfulness/acceptance-based approaches with existing cognitive behavioral models. Clin Psychol Sci Pract. 2002;9:54–68.

    Article  Google Scholar 

  23. Roemer L, & Orsillo SM. An acceptance-based behavior therapy for generalized anxiety disorder. In: S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: conceptualization and treatment 2005. pp. 213–240.

  24. • Newman MG, & Llera SJ. A novel theory of experiential avoidance in generalized anxiety disorder: a review and synthesis of research supporting a contrast avoidance model of worry. Clinical Psychology Review, 2011;31:371–382. Given the relatively low rate of end-state functioning following CBT for GAD, it is important to elucidate the basic nature of worry and GAD in the hopes of using this knowledge to develop novel treatment approaches. This new theory of GAD proposes a new conceptualization of worry that, if empirically supported in the future, may form the basis for new treatment strategies.

    Article  PubMed  Google Scholar 

  25. Llera SJ, Newman MG. Worry and emotional avoidance in generalized anxiety disorder: effects on physiological and subjective reactivity. Emotion. 2010;10(5):640–50.

    Article  PubMed  Google Scholar 

  26. Borkovec TD, Newman MG, Pincus AL, Lytle R. A component analysis of cognitive-behavioral therapy for generalized anxiety disorder and the role of interpersonal problems. J Consult Clin Psychol. 2002;70:288–98.

    Article  PubMed  CAS  Google Scholar 

  27. Behar E, Borkovec TD. The nature and treatment of generalized anxiety disorder. In: Rothbaum BO, editor. The nature and treatment of pathological anxiety: Essays in honor of Edna B. Foa. New York: Guilford; 2005. p. 181–96.

    Google Scholar 

  28. • Newman MG, Castonguay LG, Borkovec TD, Fisher AJ, Boswell JF, Szkodny LE, & Nordberg SS. A randomized controlled trial of cognitive-behavioral therapy for generalized anxiety disorder with integrated techniques from emotion-focused and interpersonal therapies. Journal of Consulting and Clinical Psychology, 2011;79:171–181. This study reports on the large-scale treatment outcome study that is based on one of the leading theories of worry and GAD. That emotion-focused and interpersonal treatment components did not enhance efficacy of traditional CBT methods raises important questions about whether the avoidance theory of worry is adequately explaining the nature of worry, and underscores the need for the development of other treatment approaches.

    Article  PubMed  Google Scholar 

  29. Robichaud M, Dugas MJ. A cognitive-behavioral treatment targeting intolerance of uncertainty. In: Davey G, Wells A, editors. Worry and its psychological disorders: theory, assessment and treatment. West Sussex: Wiley; 2006. p. 289–304.

    Chapter  Google Scholar 

  30. Wells A. The Metacognitive model of worry and generalized anxiety disorder. In: Davey G, Wells A, editors. Worry and its psychological disorders: theory, assessment and treatment. West Sussex, England: Wiley & Sons; 2006. p. 179–200.

    Google Scholar 

  31. Mennin DS, Fresco DM. Emotion regulation as an integrative framework for understanding and treating psychopathology. In: Kring AM, Sloan DM, editors. Emotion Regulation in Psychopathology: A Transdiagnostic Approach to Etiology and Treatment. New York: Guilford; 2009. p. 356–79.

    Google Scholar 

  32. • Przeworski A, Newman MG, Pincus AL, Kasoff MB, Yamasaki AS, Castonguay LG, & Berlin KS. Interpersonal pathoplasticity in individuals with generalized anxiety disorder. Journal of Abnormal Psychology, 2011;120:286–298. As with Salzer et al. [34•], this study provides important evidence regarding interpersonal subtypes within GAD. The identification of GAD subtypes is extremely important in opening the door for investigations that attempt to match treatment to individual.

    Article  PubMed  Google Scholar 

  33. Alden LE, Wiggins JS, Pincus AL. Construction of circumplex scales for the Inventory of Interpersonal Problems. J Personal Assess. 1990;55:521–36.

    CAS  Google Scholar 

  34. • Salzer S, Pincus AL, Winkelbach C, & Leichsenring F. Interpersonal subtypes and change of interpersonal problems in the treatment of patients with generalized anxiety disorder: A pilot study. Psychotherapy, 2011;48:304–310. As with Przeworski et al. [32•], this study provides important evidence regarding interpersonal subtypes within GAD. The identification of GAD subtypes is extremely important in opening the door for investigations that attempt to match treatment to individual.

    Article  PubMed  Google Scholar 

  35. Michelson SE, Lee JK, Orsillo SM, Roemer L. The role of values-consistent behavior in generalized anxiety disorder. Depression and Anxiety. 2011;28:358–66.

    Article  PubMed  Google Scholar 

  36. Tobon JI, Ouimet AJ, Dozois DJA. Attentional bias in anxiety disorders following cognitive behavioral treatment. Journal of Cognitive Psychotherapy: An International Quarterly. 2011;25:114–29.

    Article  Google Scholar 

  37. Amir M, & Taylor CT. Combining computerized home-based treatments for generalized anxiety disorder: an attention modification program and cognitive behavioral therapy. Behavior Therapy 2012.

  38. Hallion LS, Ruscio AM. A meta-analysis of the effect of cognitive bias modification on anxiety and depression. Psychol Bull. 2011;137:940–58.

    Article  PubMed  Google Scholar 

  39. Westra HA, Arkowitz H, Dozois DJA. Adding a motivational interviewing pretreatment to cognitive behavioral therapy for generalized anxiety disorder: a preliminary randomized controlled trial. Journal of Anxiety Disorders. 2009;23:1106–17.

    Article  PubMed  Google Scholar 

  40. Marcus M, Westra H, Angus L, & Kertes A. Client experiences of motivational interviewing for generalized anxiety disorder: a qualitative analysis. Psychotherapy Research, 2011;1–15.

  41. Kertes A, Westra HA, Angus L, Marcus M. The impact of motivational interviewing on client experiences of cognitive behavioral therapy for generalized anxiety disorder. Cognitive and Behavioral Practice. 2011;18:55–69.

    Article  Google Scholar 

  42. Orlinsky DE, Grawe K, Parks BK. Process and outcome in psychotherapy: Noch einmal. In: Bergin AE, Garfield SL, editors. Handbook of psychotherapy and behavior change. 4th ed. Oxford: John Wiley & Sons; 1994. p. 270–376.

    Google Scholar 

  43. Astrom M. Generalized anxiety disorder in stroke patients. A 3-year longitudinal study. Stroke. 1996;27:270–5.

    Article  PubMed  CAS  Google Scholar 

  44. Caudle DD, Senior AC, Wetherell JL, Rhoades HM, Beck JG, Kunik ME, et al. Cognitive errors, symptom severity, and response to cognitive behavior therapy in older adults with generalized anxiety disorder. American Journal of Geriatric Psychiatry. 2007;15:680–9.

    Article  PubMed  Google Scholar 

  45. de Beurs E, Beekman AT, van Balkom AJ, Deeg DJ, van Dyck R, van Tilburg W. Consequences of anxiety in older persons: its effect on disability, well-being and use of health services. Psychol Med. 1999;29:583–93.

    Article  PubMed  Google Scholar 

  46. Wolitzky-Taylor KB, Castriotta M, Lenze EJ, Stanley MA, Craske MG. Anxiety disorder in older adults: a comprehensive review. Depression and Anxiety. 2010;27:190–211.

    Article  PubMed  Google Scholar 

  47. Lenze EJ, Mantella RC, Shi P, Goate AM, Nowotny P, Butters MA, Andreescu C, Thompson PA, Rollman BL. Elevated cortisol in older adult with generalized anxiety disorder is reduced by treatment: a placebo-controlled evaluation of escitalopram. American Journal of Geriatric Psychiatry. 2011;19:482–90.

    Article  PubMed  Google Scholar 

  48. Chaudieu I, Beluche I, Norton J, Boulenger JP, Ritchie K, Ancelin ML. Abnormal reactions to environmental stress in elderly persons with anxiety disorders: evidence from a population study of diurnal cortisol changes. J Affect Disord. 2008;106:307–13.

    Article  PubMed  CAS  Google Scholar 

  49. Mantella RC, Butters MA, Amico JA, Mazumdar S, Rollman BL, Begley AE, Reynolds CF, Lenze EJ. Salivary cortisol is associated with diagnosis and severity of late-life generalized anxiety disorder. Psychoneuroendocrinology. 2008;33:773–81.

    Article  PubMed  CAS  Google Scholar 

  50. Butters MA, Bhalla RK, Andreescu C, Wetherell JL, Mantella R, Begley AE, & Lenze EJ. Changes in neuropsychological functioning following treatment for late-life generalized anxiety disorder. British Journal of Psychiatry, 2011;1-8.

  51. Gum AM, Arean PA, Hunkeler E, Tang L, Katon W, Hitchcock P, Steffens DC, Dickens J, Unützer J. Depression treatment preferences in older primary care patients. Gerontologist. 2006;46:14–22.

    Article  PubMed  Google Scholar 

  52. Lenze EJ, Rollman BL, Shear MK, Dew MA, Pollock BG, Ciliberti C, Constantino M, Snyder S, Shi P, Spitznagel E, Andreescu C, Butters MA, Reynolds CF. Escitalopram for older adults with generalized anxiety disorder: a randomized controlled trial. JAMA. 2009;301:295–303.

    Article  PubMed  CAS  Google Scholar 

  53. Metge C, Grymonpre R, Dahl M, Yogendran M. Pharmaceutical use among older adults: using administrative data to examine medication-related issues. Canadian Journal of Aging. 2005;24:81–95.

    Article  Google Scholar 

  54. Isaacowitz DM, Seligman ME. Cognitive style predictors of affect change in older adults. International Journal of Aging and Human Development. 2002;54:233–53.

    Article  PubMed  Google Scholar 

  55. Wetherell JL, Afari N, Ayers CR, Stoddard JA, Ruberg J, Sorrell JT, Liu L, Petkus AJ, Thorp SR, Kraft A, Patterson TL. Acceptance and commitment therapy for generalized anxiety disorder in older adults: a preliminary report. Behavior Therapy. 2011;42:127–34.

    Article  PubMed  Google Scholar 

  56. Davis M, Myers KM, Ressler KJ, Rothbaum BO. Facilitation of extinction of conditioned fear by d-cycloserine: implications for psychotherapy. Curr Dir Psychol Sci. 2005;14:214–9.

    Article  Google Scholar 

  57. Richardson R, Ledgerwood L, & Cranney J. Facilitation of fear extinction by d-cycloserine: theoretical and clinical implications. Learning and Memory, 2004;11, 510–516. New York: Springer.

    Google Scholar 

Download references

Disclosure

No potential conflicts of interest relevant to this article were reported.

Author information

Authors and Affiliations

  1. Hunter College, Regulation of Emotion in Anxiety and Depression Laboratory, 695 Park Avenue, Hunter North, Room 738, New York, NY, 10065, USA

    Eric J. Garfinkle

  2. University of Illinois at Chicago, 1007 West Harrison Street (MC 285), Chicago, IL, 60607, USA

    Evelyn Behar

Authors
  1. Eric J. Garfinkle
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Evelyn Behar
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Eric J. Garfinkle.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Garfinkle, E.J., Behar, E. Advances in Psychotherapy for Generalized Anxiety Disorder. Curr Psychiatry Rep 14, 203–210 (2012). https://doi.org/10.1007/s11920-012-0263-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11920-012-0263-1

Keywords

Search

Navigation