Generalized Anxiety Disorder Clients Research Articles

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

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. 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. 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. 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).

Emotion-focused perspective on generalized anxiety disorder: A qualitative analysis of clients’ in-session presentations

Objective: The classification of generalized anxiety disorder (GAD) is influenced by the tradition of conceptualizing disorders in the context of their clinical presentation and subsequent professional thinking around them. Our qualitative, descriptive-interpretative study uses a theoretical framework drawn from emotion-focused therapy (EFT) as the basis of our interpretation of GAD clients’ presentation of their difficulties. Method: The current research consists of an investigation into the GAD presentation based on a multiple case study observational qualitative design. In total, 93 video/audio-taped sessions from 14 clients were used for the analyses. The sessions were analyzed using an EFT case conceptualization framework. Results: The findings capture common themes across the cases covering the EFT framework domains: triggers of emotional pain (e.g., trauma, rejection), problematic self-treatment (e.g., worry, self-criticism, self-interruption), global distress (e.g., anxiety, low mood, somatic symptoms), apprehension/anxiety (fear of triggers and chronic painful emotions), emotional avoidance (e.g., self-distraction), behavioral avoidance (e.g., avoidance of conflict, over-compliance), core painful feelings (e.g., sadness/loneliness, shame, fear), and unmet needs (e.g., to be loved, to be acknowledged, to be protected). Conclusions: Discussion focuses on examining findings in the context of existing psychological models of GAD. The implications for practice as well as limitations of the study are also discussed.Clinical or methodological significance of this article: This is an attempt to provide an in-depth case conceptualization based on the EFT theoretical framework of the clients with GAD that attended EFT. Thus, it should contribute to clinical understanding of the presentation of the clients with GAD. Methodologically, the study uses an original qualitative approach, in which in-session presentations of 14 clients are thoroughly tracked and analyzed within an existing theoretical framework, the domains of which serve as the domains of inquiry.

The extent and nature of imagery during worry and positive thinking in generalized anxiety disorder.

Clients in treatment for Generalized Anxiety Disorder (GAD) were compared to a control group to assess the extent and nature of imagery during worry or while thinking about a personally relevant positive future event. Two methods were used to assess mentation and were completed in counter balanced order within the worry and positive conditions. One method assessed the occurrence of imagery by requiring participants to categorize their mentation as verbal thoughts or images every 10 s. The other method involved participants estimating the duration of any imagery that occurred in the previous 10 s. Imagery during worry occurred less often than while thinking about a positive event for both groups, but GAD clients had a more pronounced deficit of imagery during worry than the control group. Images that occurred were briefer during worry than while thinking about a positive future event and were briefer in the GAD than the control group for both worry and positive conditions. The results thus confirmed that imagery is less common during worry in clients with GAD but also demonstrated that the imagery that does occur in GAD is briefer.

The role of values-consistent behavior in generalized anxiety disorder

Theory and research suggest that generalized anxiety disorder (GAD) is associated with diminished quality of life and restriction in valued action. The purpose of this study was to examine the relevance of values-consistent behavior (valued action) in understanding the impairment in quality of life in GAD. Treatment-seeking clients with a principal diagnosis of GAD (n = 30) were compared with demographically matched nonanxious controls (n = 30) using self-report measures. Participants with GAD reported significantly less valued action compared with controls, and within the GAD group, diminished valued action was not fully explained by depression comorbidity. Valued action was significantly correlated with measures of experiential avoidance, distress about emotions, and quality of life. Further, consistent with a theoretical model of GAD, restrictions in valued action contributed unique variance to diminished quality of life over and above the contributions of gender, GAD severity, experiential avoidance, distress about emotions, and depression comorbidity. Finally, an acceptance-based behavioral therapy significantly improved self-reports of valued action for GAD clients with 40% achieving clinically significant change in this domain. The findings provide preliminary support for the relevance of valued action in understanding the functional impairment associated with GAD, and the beneficial effects of an acceptance-based behavior therapy in increasing valued action.

The effects of modifying interpretation bias on worry in generalized anxiety disorder

This study investigated whether facilitating a benign interpretive bias decreases negative thought intrusions in generalized anxiety disorder (GAD). Clients were randomly allocated to an interpretation modification condition in which they repeatedly accessed benign meanings of emotionally ambiguous homographs and scenarios, or to a control condition in which they accessed threat and benign meanings with equal frequency. Worry frequency was assessed using a breathing focus task that involved categorising the valence of thought intrusions before and after an instructed worry period. Interpretation bias was assessed during the modification tasks, and on a different measure of interpretation bias (sentence completion) following a period of worry. The experimental procedure modified interpretations made during training, and in the later sentence completion task. Furthermore, compared to the control group, the benign group showed fewer negative thought intrusions during breathing focus (as rated by both participants and an assessor). These findings show that it is possible to induce a more benign interpretive bias in GAD clients and that this reduces negative thought intrusions.

Generalized Anxiety Disorder: Connections With Self-Reported Attachment

Even though generalized anxiety disorder (GAD) is one of the most common of the anxiety disorders, relatively little is known about its precursors. Bowlby's attachment theory provides a framework within which these precursors can be considered. According to Bowlby, adult anxiety may be rooted in childhood experiences that leave a child uncertain of the availability of a protective figure in times of trouble. Furthermore, adult “current state of mind with respect to attachment” is thought to relate to adult anxiety. Both attachment-related components were assessed with 8 subscales of the Perceptions of Adult Attachment Questionnaire (PAAQ). Clinically severe GAD clients who were about to begin therapy reported experiencing less maternal love in childhood, greater maternal rejection/neglect, and more maternal role-reversal/enmeshment than did control participants. In keeping with a cumulative risk model, risk for GAD increased as indices of poor childhood attachment experience increased. GAD clients, in contrast to controls, also reported greater current vulnerability in relation to their mothers as well as more difficulty accessing childhood memories. Logistic regression analyses revealed that elevations on PAAQ subscales could significantly predict GAD vs. non-GAD status. Results and the implications for advancing the theory and treatment of GAD are discussed.

Reduced concreteness of worry in generalized anxiety disorder: Findings from a therapy study

A sample of clients diagnosed with generalized anxiety disorder (GAD) provided descriptions of the two major problems they worried about and of potential negative consequences associated with these problems, once before and once after they received cognitive–behavioral therapy. When descriptions were rated for concreteness and compared to those of normal controls, results showed that untreated GAD clients provided less concrete descriptions of their major worries relative to controls. After successful therapy, problem descriptions of GAD clients showed the same level of concreteness as those of controls. These findings add further support to the reduced-concreteness theory of worry. Moreover, they indicate that concretization of worries may play a prominent role in the reduction of pathological worry.

Compulsive checking behaviors in generalized anxiety disorder.

Recent evidence suggests that a relationship exists between worry, the central feature of generalized anxiety disorder (GAD), and compulsive behaviors, particularly compulsive checking. In this article we report the results from two studies. The first study assessed the frequency of obsessions and compulsions in 107 principally diagnosed GAD clients. The second study examined levels of alexithymia in analogue samples of GAD checkers (n = 31), GAD noncheckers (n = 30), and non-GAD nonchecking controls (n = 27) using the Toronto Alexithymia Scale-20 (Bagby, Parker, & Taylor, 1994). The results from these studies suggest that compulsive behaviors in the form of compulsive checking is more common in GAD than previously expected and that such behaviors in GAD may act as an additional mechanism by which affective experiences are avoided.

Phasic heart period reactions to cued threat and nonthreat stimuli in generalized anxiety disorder

The hallmark of generalized anxiety disorder (GAD) is chronic uncontrollable worry. A preattentive bias toward threat cues and hypervigilance may support this ongoing state of apprehension. A study was conducted to bridge the attentional and physiological underpinnings of GAD by examining phasic heart period (HP) responses to cued threat and nonthreat stimuli. Thirty-three GAD clients and 33 nonanxious control participants engaged in an S1-S2 procedure that employed cued threat and nonthreat word stimuli, during which phasic HP reactions were recorded. As compared with the control group, the GAD group showed (1) smaller cardiac orienting responses and impaired habituation of cardiac orienting to neutral words, (2) HR acceleration in response to threat words, and (3) a conditioned anticipatory HR deceleration to threat words over repeated trials. The cardiac-autonomic underpinnings of GAD appear to rigidly maintain precognitive defensive responses against threat. This portrayal is discussed in the context of an integrative model that depicts diminished global adaptive variability in GAD.

Phasic heart period reactions to cued threat and nonthreat stimuli in generalized anxiety disorder

The hallmark of generalized anxiety disorder (GAD) is chronic uncontrollable worry. A preattentive bias toward threat cues and hypervigilance may support this ongoing state of apprehension. A study was conducted to bridge the attentional and physiological underpinnings of GAD by examining phasic heart period (HP) responses to cued threat and nonthreat stimuli. Thirty-three GAD clients and 33 nonanxious control participants engaged in an S1-S2 procedure that employed cued threat and nonthreat word stimuli, during which phasic HP reactions were recorded. As compared with the control group, the GAD group showed (1) smaller cardiac orienting responses and impaired habituation of cardiac orienting to neutral words, (2) HR acceleration in response to threat words, and (3) a conditioned anticipatory HR deceleration to threat words over repeated trials. The cardiac-autonomic underpinnings of GAD appear to rigidly maintain precognitive defensive responses against threat. This portrayal is discussed in the context of an integrative model that depicts diminished global adaptive variability in GAD.

Explicit memory bias for threat words in generalized anxiety disorder

Although findings of an implicit memory bias for threat words in generalized anxiety disorder (GAD) are fairly robust, the data regarding an explicit bias in this disorder are less consistent. This issue was investigated in the context of two studies directed primarily at the examination of attentional and physiological underpinnings of GAD. In these experiments, GAD clients and nonanxious control participants (35 and 29 in Study 1, and 22 and 31 in Study 2, respectively) engaged in an S1–S2 conditioning procedure that involved the presentation of a series of neutral stimuli (colored dots) paired with threat and nonthreat words, followed by a free recall test. Instructions were to simply look at the dot and read the word silently. A free recall task was administered at the end of each experimental session. Contrary to previous trends in the literature, a marked bias in the GAD group toward recall of the threat words emerged in both studies. These results are considered in the light of methodological differences with previous research, information processing characteristics of GAD, and the role of physiological assessment in cognitive studies of anxiety.

Autonomic characteristics of generalized anxiety disorder and worry

Autonomic characteristics of generalized anxiety disorder (GAD) and worry were examined using measures of heart period variability. The cardiorespiratory responses of 34 GAD clients and 32 nonanxious control subjects were recorded during resting baseline, relaxation, and worry periods. Results indicated differences between GAD subjects and controls as well as among baseline, relaxation, and worry periods. GAD clients exhibited shorter cardiac interbeat intervals (IBIs) and lower high frequency spectral power across all task conditions. Relative to baseline and relaxation conditions, worry was associated with (1) shorter IBIs, (2) smaller mean successive differences (MSD) of the cardiac IBIs, and (3) lower high frequency spectral power. These findings suggest that GAD and its cardinal feature (worry), are associated with lower cardiac vagal control. The findings of the present study provide evidence for the utility of further exploration of the role of autonomic nervous system activity in GAD.

Generalizability of DSM-III-R generalized anxiety disorders to proposed DSM-IV criteria and cross-validation of proposed changes

Proposed changes in the diagnostic criteria for generalized anxiety disorder (GAD) in DSM-IV could affect the generalizability of prior research on DSM-III-R GAD. It would thus be important to determine whether clients selected by the differing criteria are similar or dissimilar. Replication of the results that led to the proposed changes would also be useful for strengthening their validity. We examined 40 clients with DSM-III-R GAD and 36 nonanxious subjects using a modified Anxiety Disorders Interview Schedule and a self-report questionnaire, both of which included questions relevant to the proposed changes. All DSM-III-R GAD clients met DSM-IV criteria, the proposed diagnostic features were found to be highly prevalent among the clients, and these features significantly differentiated the clients from control subjects. The results provide further empirical support for the proposed DSM-IV diagnostic criteria for GAD and suggest that these criteria will allow for continuity in GAD research.

The nature of worry in generalized anxiety disorder: A predominance of thought activity

Indirect evidence suggests that worry primarily involves thought, rather than imaginal, activity, a distinction within cognitive process that is potentially crucial to some theories of anxiety maintenance and modification. The present study constrasted the frequencies of reporting the presence of thoughts and images among generalized anxiety disorder clients and matched, nonanxious control subjects during a self-relaxation period and a worry period. Repetition of the assessment was conducted with clients after they completed 12 sessions of therapy. Sampling of mentation during these periods revealed that (a) during relaxation, nonanxious subjects reported a predominance of imagery whereas clients show equal amounts of thought and imagery, (b) nonanxious subjects shifted to a predominance of thought during worry, and (c) clients showed a normalization of thought and image frequencies after successful therapy. This combination of results suggests that worry is principally thought-like in content. The speculation is offered that worry may function as motivated avoidance of emotional imagery and its attendant somatic sensations.