Abstract
Generalized anxiety disorder (GAD), with uncontrollable worry at its core, is a common psychological disorder with considerable individual and societal costs. Cognitive behavior therapy (CBT) is recommended as the first-line treatment for GAD; however, further investigation into its effectiveness in routine clinical care is indicated and improvement is required in treatment outcomes for worry. Improvements to CBT need to be guided by experimental research that identifies key mechanisms maintaining core aspects of the disorder. This paper summarizes how theory-driven experimental research guided selection and refinements of CBT techniques originally developed by Borkovec and Costello, to target key cognitive processes that maintain worry in GAD. Hirsch and Mathews’ model specifies three key research-supported processes that maintain uncontrollable worry in GAD: implicit cognitive biases such as negative interpretation bias and attention bias, generalized verbal thinking style, and impaired ability to re-direct attentional control away from worry. Specific CBT techniques outlined in this paper aim to target these key processes. Clinical data from clients treated using our refined CBT protocol for GAD in a routine clinical care service with a special interest in anxiety disorders were collected as part of service procedures. Large pre-to-posttreatment effect sizes were obtained for anxiety (GAD-7), depression (PHQ-9), and worry (PSWQ) (d=.90–2.54), and a moderate effect size was obtained for quality of life (WASA; d=.74). Recovery was indicated for 74% of cases for anxiety, 78% for depression, and 53% for worry. These findings exceeded most previous effectiveness studies in routine care and were in-line with GAD efficacy trials. This paper also outlines the application of specific clinical techniques selected, adapted or developed to target key cognitive mechanisms which maintain worry in GAD.
Highlights
Generalized anxiety disorder (GAD) is a common and disabling condition with the hallmark symptom of persistent, excessive, and uncontrollable worry across a number of different topics [1]
This paper presents an audit conducted in an National Health Service (NHS) routine clinical service of an adaptation of Borkovec et al [38] Cognitive behavior therapy (CBT) protocol to focus on techniques that target key cognitive processes outlined in Hirsch and Mathews [41] cognitive model
Significant differences were found between the pre-treatment and post-treatment questionnaire for all measures, with large effects indicated for the Penn State Worry Questionnaire (PSWQ), Generalized Anxiety Disorder-7 (GAD-7) and PHQ-9, and moderate effects for the Work and Social Adjustment Scale (WSAS)
Summary
Generalized anxiety disorder (GAD) is a common and disabling condition with the hallmark symptom of persistent, excessive, and uncontrollable worry across a number of different topics [1]. Hirsch et al [49] showed that cognitive bias modification of interpretation, which was designed to train high worriers to interpret ambiguous information more positively, facilitated a more benign interpretive bias and fewer negative thought intrusions, and led to less impairment of attentional control during worry. Because each causal process can exert its effects on negative thought in different ways [41], achieving optimal improvements is likely to require targeting all of them in CBT This may be achieved by facilitating more adaptive focus onto benign information (via intentional allocation of attentional control or more automated development of benign attention and interpretation biases), or engagement in more helpful thinking styles (concrete and specific imagery) evident in non-anxious populations. 3) 50% of clients would achieve recovery on the PSWQ posttreatment (which would be in keeping with gold standard RCTs)
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