Generalized Anxiety Disorder Participants Research Articles

Impact of comorbid sleep-disordered breathing on escitalopram treatment in patients newly diagnosed with generalized anxiety disorder: A 12-week prospective observational study

We aimed to evaluate the presence of sleep-disordered breathing (SDB) in generalized anxiety disorder (GAD) patients and its impacts after 12-week of escitalopram treatment. In this prospective observational study, GAD patients were followed up to determine whether comorbid SDB affects their treatment response. They underwent a home sleep apnea test (HSAT), and oxygen desaturation index ≥5 was considered indicative of SDB. All participants were treated with escitalopram 5 mg in the first 2 weeks and 10 mg in the remaining 10 weeks. They underwent assessments of heart rate variability and completed questionnaires for sleep, mood, attention, and daytime sleepiness on the day of enrollment, and 2 weeks, 4 weeks, and 12 weeks later. A total of 45 GAD participants (mean age, 56.2 years) were included in the study. Of these, 53.3% had comorbid SDB. Participants with GAD and SDB had higher baseline Beck Anxiety Inventory (BAI) and STOP-BANG scores. Both groups of participants with GAD showed overall improvement in anxiety, depression, and insomnia symptoms after 12 weeks of escitalopram treatment. Additionally, there were no statistically significant differences in the changes in BAI, Beck Depression Inventory, and Epworth Sleepiness Scale scores between the two groups at the Week 2, Week 4, and Week 12 assessments compared to baseline. However, the GAD group with comorbid SDB seemed to have a lower tendency for improvement in depressive symptoms than the group with non-comorbid SDB. Compared with the GAD group without comorbid SDB, the GAD group with comorbid SDB exhibited more severe anxiety symptoms at baseline and tended to show less improvement in depressive symptoms after 12 weeks of escitalopram treatment.

Prevalence and effects of sleep-disordered breathing on middle-aged patients with sedative-free generalized anxiety disorder: A prospective case-control study.

Generalized anxiety disorder (GAD) and sleep-disordered breathing (SDB) share similar symptoms, such as poor sleep quality, irritability, and poor concentration during daily activities. This study aims to investigate the proportion of undiagnosed SDB and its impacts on anxiety severity and autonomic function in newly diagnosed, sedative-free GAD patients. This prospective case-control study included newly diagnosed GAD patients and control participants with matched age, sex, and body mass index (BMI) in Taiwan. All participants completed questionnaires for sleep and mood symptoms and a resting 5-min heart rate variability (HRV) examination during enrollment. The participants also used a home sleep apnea test to detect SDB. An oxygen desaturation index (ODI) ≥ 5 was considered indicative of SDB. In total, 56 controls and 47 newly diagnosed GAD participants (mean age 55.31 ± 12.36 years, mean BMI 23.41 ± 3.42 kg/m2) were included. There was no significant difference in the proportion of undiagnosed SDB in the control and sedative-free GAD groups (46.43 vs. 51.06%). Sedative-free GAD patients with SDB scored significantly higher on Beck Anxiety Inventory (23.83 ± 11.54) than those without SDB (16.52 ± 10.61) (p < 0.001). Both control and sedative-free GAD groups with SDB had worse global autonomic function than the control group without SDB, as evidenced by the HRV results (p < 0.05 for all). Average age 55 years and mean BMI 23 kg/m2 patients with GAD and matched controls had an undiagnosed SDB prevalence of approximately 50%. SDB correlated with worsening anxiety severity and reduced cardiac autonomic function. Moreover, age and BMI were considered major risk factors for predicting undiagnosed SDB.

Altered Interoceptive Processing in Generalized Anxiety Disorder-A Heartbeat-Evoked Potential Research.

Generalized anxiety disorder (GAD) is one of the most common anxiety disorders. The brain’s dysfunctional processing of interoceptive information is increasingly recognized as an important component of anxiety disorders. However, the neural mechanisms remain insufficiently understood. In the present study, patients with GAD and healthy control participants underwent an eyes-closed (EC) resting state (interoception) and eyes-open (EO) resting state (exteroception) without paying conscious attention to heartbeat. Electrocardiography (ECG) and electroencephalography (EEG) signals were recorded at the same time. The results show that in healthy controls, the heartbeat-evoked brain potential (HEP) was modulated by the conditions, with a significantly higher amplitude under EC than EO, while this was not the case in GAD patients. Further analysis revealed that the dysfunction of HEP modulation in GAD patients may be attributed to excessive interoceptive processing under EO, with a marginally higher HEP in GAD than in the healthy controls. Finally, the right prefrontal HEP amplitude during EC condition was significantly correlated with the severity of the patients’ anxiety symptoms. Our results suggest that altered cortical processing of interoceptive signals may play an important role in the pathophysiology of generalized anxiety disorder.

Affective flexibility and generalized anxiety disorder: valence-specific shifting difficulties

ABSTRACTBackground: Growing evidence suggests that generalized anxiety disorder (GAD) is associated with poor affective flexibility, defined as the ability to switch between emotional aspects and non-emotional aspects of a situation. However, it is unclear whether affective inflexibility is valence-specific in GAD.Methods: Participants with GAD (n = 21) and non-clinical control participants (n = 28) were tested on an Affective Switching Task during which participants were asked to categorize pictures either by the valence or by the number of humans present in the pictures.Results: Individuals with GAD, but not healthy controls, exhibited greater difficulty shifting from emotional aspects of negative material compared to emotional aspects of positive material and shifting to the emotional aspects of positive material compared to emotional aspects of negative material.Conclusions: These findings suggest that GAD is associated with valence-specific affective flexibility biases. The relevance of the findings and directions for future research are discussed.

Brain structural changes in late-life generalized anxiety disorder

Late-life Generalized Anxiety Disorder (GAD) is relatively understudied and the underlying structural and functional neuroanatomy has received little attention. In this study, we compare the brain structural characteristics in white and gray matter in 31 non-anxious older adults and 28 late-life GAD participants.Gray matter indices (cortical thickness and volume) were measured using FreeSurfer parcellation and segmentation, and mean diffusivity was obtained through Diffusion Tensor Imaging (DTI). We assessed both macroscopic white matter changes [using white matter hyperintensity (WMH) burden] and microscopic white matter integrity [using fractional anisotropy (FA)].No differences in macro- or microscopic white matter integrity were found between GAD and non-anxious controls (HC). GAD participants had lower cortical thickness in the orbitofrontal cortex (OFC), inferior frontal gyrus, and pregenual anterior cingulate cortex (ACC). Higher worry severity was associated with gray matter changes in OFC, ACC and the putamen. The results did not survive the multiple comparison correction, but the effect sizes indicate a moderate effect.The study suggests that late-life GAD is associated with gray matter changes in areas involved in emotion regulation, more so than with white matter changes. We conclude that anxiety-related chronic hypercortisolemia may have a dissociative effect on gray and white matter integrity.

Emotion Reactivity and Cerebrovascular Burden in Late-Life GAD: A Neuroimaging Study

Generalized anxiety disorder (GAD) in older adults is associated with persistent deficits in emotion reactivity (ER) and regulation, yet the neural basis of these deficits has not been explored. This study focuses on the neural basis of ER deficits in late-life GAD and the association with cerebrovascular burden. Twenty elderly nonanxious participants and 17 late-life GAD participants were included. The faces-shapes functional magnetic resonance imaging task was used to assess ER; the Hamilton Anxiety Rating Scale and the Penn State Worry Questionnaire to measure global anxiety and worry, respectively; linear regression models to examine the association between ER and global anxiety severity and between ER and worry severity; and mediation analysis to explore the effect of ER on the relationship between global anxiety/worry severity and cerebrovascular burden. A positive association was found between ER and global anxiety in the left parahippocampus, left and right precuneus, and right superior occipital gyrus. A negative association was found between ER and worry severity in the left and right precuneus. The association between cerebrovascular burden and anxiety/worry severity was indirectly mediated by increased ER in limbic and paralimbic areas and by decreased ER in prefrontal regulatory regions. These results indicate that ER is associated with different neural activation patterns for worry and global anxiety and that ER-related functional connectivity indirectly mediates the relationship between cerebrovascular burden and late-life GAD. This latter result supports a yet-unexplored cerebrovascular pathway involved in the pathophysiology of late-life anxiety.

The Met allele of BDNF Val66Met polymorphism is associated with increased BDNF levels in generalized anxiety disorder.

Generalized anxiety disorder (GAD) is a common psychiatric disorder characterized by long-term worry, tension, nervousness, fidgeting, and symptoms of autonomic system hyperactivity. The neurobiology of this disorder is still unclear, although it has been shown consistently that the environment and the genetic profile could increase its risk. We examined whether a polymorphism in the brain-derived neurotrophic factor (BDNF) gene, which plays a role in neuroplasticity and memory, could increase the vulnerability to this disorder. In our study, 816 participants from a population-based study were genotyped by qPCR for the BDNF functional variant rs6265 (Val66Met) and the BDNF serum levels were measured by ELISA. Our results showed a significant association between the Met allele and risk for GAD (P=0.014), but no differences were observed in the serum levels of BDNF according to diagnosis (P=0.531) or genotype distribution (P=0.197). However, after stratification according to the GAD diagnosis, the Met allele was associated significantly with an increase in serum BDNF levels compared with the Val/Val genotype in GAD participants (F=3.93; P=0.048). The logistic regression analysis confirmed the independent association of Met allele as a risk factor for development of GAD after adjusting for confounder variables (β=0.528; 95% confidence interval: 0.320-0.871; P=0.012). These results suggest that BDNF could be involved in the neurobiology of GAD and might represent a useful marker associated with the disease.

Episodic future thinking in generalized anxiety disorder

Research on future-oriented cognition in generalized anxiety disorder (GAD) has primarily focused on worry, while less is known about the role of episodic future thinking (EFT), an imagery-based cognitive process. To characterize EFT in this disorder, we used the experimental recombination procedure, in which 21 GAD and 19 healthy participants simulated positive, neutral and negative novel future events either once or repeatedly, and rated their phenomenological experience of EFT. Results showed that healthy controls spontaneously generated more detailed EFT over repeated simulations. Both groups found EFT easier to generate after repeated simulations, except when GAD participants simulated positive events. They also perceived higher plausibility of negative—not positive or neutral—future events than did controls. These results demonstrate a negativity bias in GAD individuals’ episodic future cognition, and suggest their relative deficit in generating vivid EFT. We discuss implications for the theory and treatment of GAD.

Impaired Retrieval Inhibition of Threat Material in Generalized Anxiety Disorder.

Generalized Anxiety Disorder (GAD) is characterized by cognitive biases toward threat-relevant information, but the underlying mechanisms are unclear. We translated a retrieval-practice paradigm from cognitive science to investigate impaired inhibition of threat information as one such mechanism. Participants diagnosed with GAD and never-disordered control participants learned a series of cue-target pairs; whereas some cues were associated only with neutral targets, others were associated with both neutral and threat targets. Next, participants practiced retrieving neutral targets, which typically suppresses the subsequent recall of unpracticed associated targets (retrieval-induced forgetting; RIF). Finally, participants were tested on their recall of all targets. Despite showing intact RIF of neutral targets, the GAD group failed to exhibit RIF of threat targets. Furthermore, within the GAD group, less RIF of threat targets correlated with greater pervasiveness of worry. Deficits in inhibitory control over threat-relevant information may underlie the cognitive pathology of GAD, which has important treatment implications.

Cognitive-behavioral therapy for generalized anxiety disorder is associated with attenuation of limbic activation to threat-related facial emotions

BackgroundThe neural processes underlying the benefits of cognitive behavioral treatment (CBT) for generalized anxiety disorder (GAD) are not well understood. MethodsTwenty-one (n=21) adults with a principal diagnosis of GAD and eleven (n=11) non-anxious healthy controls (HC) underwent functional magnetic resonance imaging while completing a facial emotion processing task. Responses to threat-related emotionality (i.e., the contrast of fear and angry vs. happy faces) were assessed at pretreatment and again following 10 sessions of CBT in the GAD group and a comparable waiting period in the HC group. ResultsAt pretreatment, GAD participants displayed blunted responses in the amygdala, insula, and anterior cingulate to the happy face-processing comparison condition, and greater amygdalo–insular connectivity. CBT was associated with attenuated amygdalar and subgenual anterior cingulate activation to fear/angry faces and heightened insular responses to the happy face comparison condition, but had no apparent effects on connectivity. Pre-treatment abnormalities and treatment-related changes were not associated with symptoms of worry. LimitationsThere was no active control condition (e.g., treatment waitlist) for comparison of treatment effects. ConclusionsTaken together, these results provide evidence for a dual-process psychotherapeutic model of neural systems changes in GAD in which cingulo-amygdalar reactivity to threat-cues is attenuated while insular responses to positive facial emotions are potentiated. Future work is needed to determine the clinical implications of these changes and their specificity to CBT.

Are attentional control resources reduced by worry in generalized anxiety disorder?

This is the first study to examine attentional control capacities in generalized anxiety disorder (GAD). GAD is characterized by uncontrollable worry. Individuals diagnosed with GAD and healthy participants (HPs) performed a random key-pressing task while thinking about a worrisome or a positive future event, to assess the extent to which attentional control resources are used by worry. Attentional control was also assessed when participants were not instructed to think about a specific topic using the N-back task, which varies in task difficulty, and therefore is sensitive to subtle differences in ability to handle increasing demands on attentional control within the same paradigm. GAD participants (but not HPs) were less random while worrying than thinking about a positive event during the key-pressing task, suggesting that worry consumed more attentional control resources in this population. During the N-Back task, GAD participants performed worse than HPs during the high load conditions only, indicating greater difficulty in sustaining focus on conditions requiring a higher degree of attentional control, even without concurrent task activity. Poor attentional control might underpin the difficulty of GAD individuals to stop worrying and switch to thinking more benign information. Further research could investigate whether worry consumes attentional control resources in other psychological disorders with high rates of worry (e.g., panic disorder, psychosis), as well as the extent to which attentional control is used by other forms of repetitive thinking, such as depressive rumination.

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.

The ages of anxiety—differences across the lifespan in the default mode network functional connectivity in generalized anxiety disorder

Generalized anxiety disorder (GAD) is one of the most prevalent anxiety disorders, but its neural basis is relatively understudied. This study aims to characterize the functional connectivity in the default mode network (DMN) in GAD across the lifespan. Functional and structural magnetic resonance imaging data were collected with subjects at rest. We analyzed the resting state functional connectivity patterns in the DMN for 27 GAD participants and 39 non-anxious comparison participants. Using a two-way analysis of variance, we explored the interaction between age and GAD status on functional connectivity. In GAD participants, we analyzed the correlation of functional connectivity indices with the duration of illness and worry severity. The age-by-anxiety interaction showed a greater anxiety effect on the functional connectivity between the posterior cingulate seed and the medial prefrontal cortex for the older group relative to the younger participants. Longer duration of illness was positively correlated with greater functional connectivity between the posterior cingulate cortex and the insula. Worry severity was inversely correlated with the functional connectivity between the posterior cingulate cortex seed and the medial prefrontal cortex. The presence of GAD, longer duration of illness, and more severe worry exacerbate the effects of age on the functional connectivity in the DMN. These results support the need for tailored research and interventions in late-life anxiety.

Heart rate and autonomic response to stress after experimental induction of worry versus relaxation in healthy, high-worry, and generalized anxiety disorder individuals

Generalized anxiety disorder (GAD) is the most commonly occurring anxiety disorder and has been related to cardiovascular morbidity such as cardiac ischemia, sudden cardiac death, and myocardial infarction. Both GAD and its cardinal symptom – worry – have been shown to promote muted physiological reactivity in response to laboratory and ecological stressors. Importantly, no study to date has examined the concurrent and relative contributions of trait and state worry within healthy controls, (non-clinical) high trait-worry controls, and GAD participants. The present study examined heart rate (HR), respiratory sinus arrhythmia (RSA), and salivary alpha-amylase (sAA) responses to laboratory stress during and following the experimental induction of worry versus relaxation in healthy controls (n=42), high trait worriers (n=33) and participants with GAD (n=76). All groups exhibited increased HR and decreased RSA in response to the stressor, with no differences by condition. Baseline sAA significantly moderated HR and RSA reactivity, such that higher sAA predicted greater increases in HR and decreases in RSA. There was a significant group by baseline sAA interaction such that in GAD, higher baseline sAA predicted decreased change in sAA during stress, whereas higher baseline sAA predicted greater sAA change in healthy controls. High-worry controls fell non-significantly between these groups. The present study provides additional evidence for the effect of worry on diminished HR stress response and points to possible suppression of adrenergic sympathetic stress responses in GAD.

Association of cortisol with neuropsychological assessment in older adults with generalized anxiety disorder

Objectives: Older adults with generalized anxiety disorder (GAD) have elevated diurnal cortisol patterns and show an increased cortisol stress response, which may increase risk for cognitive dysfunction. The current secondary data analysis examined how neuropsychological assessment as a possible laboratory stressor affects cortisol levels in late-life GAD and, in turn, how cortisol levels affect cognitive performance. Methods: The current sample consisted of 69 individuals with late-life GAD and 39 psychiatrically healthy group-matched comparison participants. Cognitive performance was measured with a neuropsychological battery and salivary cortisol was collected at several time points. Hierarchical regressions were performed to assess the moderating role of cortisol in the relationship between GAD status and cognitive performance. Results: The results revealed that older adults with GAD showed significantly lower cortisol levels during neuropsychological assessment, compared to their baseline levels. Further, there was a significant interaction between post-neuropsychological assessment cortisol levels and GAD status on several measures of cognitive performance. The interaction indicated that there is a significant negative relationship between cortisol level and cognitive performance in the GAD participants and no such relationship in the comparison participants. Conclusions: Our results revealed that participating in a neuropsychological assessment was associated with reduced cortisol in GAD participants, suggesting that refocusing attention such as engaging in cognitive tasks had a cortisol-lowering effect. Further, a higher cortisol level appears to have a detrimental effect on cognitive performance for individuals with GAD, but not psychiatrically healthy comparison participants. The methodological and treatment implications of these findings are discussed.

Anxiety, Social Support, and Physical Health in a Sample of Spouses of OEF/OIF Service Members

The goal of this study was to examine the relationships between heightened anxiety, social support, and physical health in a sample of spouses of returning Iraq and Afghanistan service members. 86 spouses were recruited nationally as part of a pilot trial of a military spouse telephone support group. Participants completed measures of physical and mental health via telephone including a screening tool for generalized anxiety disorder (GAD). Scores for social support and health outcomes were compared across two groups (positive vs. negative screens for GAD) using one-way analysis of variance analysis procedures. Path analytic techniques were used to evaluate the relative effects of anxiety and perceived social support on overall health and physical health comorbidities. A total of 38 participants screened positive for GAD. Participants with probable GAD reported having less social support than those screening negative for GAD. GAD participants also reported poorer overall health and more physical health comorbidities than their GAD-negative counterparts. Path analysis indicated that heightened anxiety is associated with worse overall health and social support does not buffer this interaction. The results suggest that anxiety-related health is a critical factor to be addressed in spouses of service members.

Prefrontal dysfunction during emotion regulation in generalized anxiety and panic disorders

The mechanisms that contribute to emotion dysregulation in anxiety disorders are not well understood. Two common disorders, generalized anxiety disorder (GAD) and panic disorder (PD), were examined to test the hypothesis that both disorders are characterized by hypo-activation in prefrontal cortex (PFC) during emotion regulation. A competing hypothesis that GAD in particular is characterized by PFC hyper-activation during emotion regulation (reflecting overactive top-down control) was also evaluated. Method Twenty-two medication-free healthy control (HC), 23 GAD, and 18 PD participants underwent functional magnetic resonance imaging (fMRI) during a task that required them to reappraise (i.e. reduce) or maintain emotional responses to negative images. GAD participants reported the least reappraisal use in daily life, and reappraisal use was inversely associated with anxiety severity and functional impairment in these participants. During fMRI, HCs demonstrated greater activation during both reappraisal and maintenance than either GAD or PD participants (who did not differ) in brain areas important for emotion regulation (e.g. dorsolateral and dorsomedial PFC). Furthermore, across all anxious participants, activation during reappraisal in dorsolateral and dorsomedial PFC was inversely associated with anxiety severity and functional impairment. Emotion dysregulation in GAD and PD may be the consequence of PFC hypo-activation during emotion regulation, consistent with insufficient top-down control. The relationship between PFC hypo-activation and functional impairment suggests that the failure to engage PFC during emotion regulation may be part of the critical transition from dispositionally high anxiety to an anxiety disorder.

GENERALIZABILITY OF CLINICAL TRIAL RESULTS FOR GENERALIZED ANXIETY DISORDER TO COMMUNITY SAMPLES

There has been little research on the generalizability of clinical trials for generalized anxiety disorder (GAD). The present study examines the generalizability of pharmacological and psychotherapy clinical trials' results of individuals with DSM-IV GAD to a large community sample. Data were drawn from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), a large national representative face-to-face sample of 43,093 adults of the United States population. We applied a standard set of eligibility criteria representative of GAD pharmacological and psychotherapy clinical trials to all adults with past 12 months GAD (n = 894), and to a subgroup of participants seeking treatment (n = 329). Our aim was to assess how many participants with GAD would fulfil typical eligibility criteria. We found that more than seven out of 10 participants with GAD were excluded by at least one criterion. In the subgroup of GAD participants who sought treatment, the exclusion rate by at least one criterion raised to more than eight out of 10 participants with GAD. For the overall sample and the treatment-seeking subsample, having a current depression was the criterion excluding the highest percentage of individuals. Having a lifetime history of bipolar disorder, a current significant medical condition, a current diagnosis of alcohol abuse or dependence, and a social or specific phobia also excluded a substantial proportion of individuals in both samples. Clinical trials exclude a majority of adults with GAD. Clinical trials should carefully consider the impact of eligibility criteria on the generalizability of their results.

Deficient prefrontal attentional control in late-life generalized anxiety disorder: an fMRI investigation

Younger adults with anxiety disorders are known to show an attentional bias toward negative information. Little is known regarding the role of biased attention in anxious older adults, and even less is known about the neural substrates of any such bias. Functional magnetic resonance imaging (fMRI) was used to assess the mechanisms of attentional bias in late life by contrasting predictions of a top-down model emphasizing deficient prefrontal cortex (PFC) control and a bottom-up model emphasizing amygdalar hyperreactivity. In all, 16 older generalized anxiety disorder (GAD) patients (mean age=66 years) and 12 non-anxious controls (NACs; mean age=67 years) completed the emotional Stroop task to assess selective attention to negative words. Task-related fMRI data were concurrently acquired. Consistent with hypotheses, GAD participants were slower to identify the color of negative words relative to neutral, whereas NACs showed the opposite bias, responding more quickly to negative words. During negative words (in comparison with neutral), the NAC group showed PFC activations, coupled with deactivation of task-irrelevant emotional processing regions such as the amygdala and hippocampus. By contrast, GAD participants showed PFC decreases during negative words and no differences in amygdalar activity across word types. Across all participants, greater attentional bias toward negative words was correlated with decreased PFC recruitment. A significant positive correlation between attentional bias and amygdala activation was also present, but this relationship was mediated by PFC activity. These results are consistent with reduced prefrontal attentional control in late-life GAD. Strategies to enhance top-down attentional control may be particularly relevant in late-life GAD treatment.

A randomized controlled trial of cognitive-behavioral therapy for generalized anxiety disorder with integrated techniques from emotion-focused and interpersonal therapies.

Recent models suggest that generalized anxiety disorder (GAD) symptoms may be maintained by emotional processing avoidance and interpersonal problems. This is the first randomized controlled trial to test directly whether cognitive-behavioral therapy (CBT) could be augmented with the addition of a module targeting interpersonal problems and emotional processing. Eighty-three primarily White participants (mean age = 37) with a principle diagnosis of GAD were recruited from the community. Participants were assigned randomly to CBT plus supportive listening (n = 40) or to CBT plus interpersonal and emotional processing therapy (n = 43) within a study using an additive design. Doctoral-level psychologists with full-time private practices treated participants in an outpatient clinic. Using blind assessors, participants were assessed at pretreatment, posttreatment, 6-month, 1-year, and 2-year follow-up with a composite of self-report and assessor-rated GAD symptom measures (the Penn State Worry Questionnaire; T. J. Meyer, M. L. Miller, R. L. Metzger, & T. D. Borkovec, 1990; Hamilton Anxiety Rating Scale; M. Hamilton, 1959; assessor severity rating; State-Trait Anxiety Inventory-Trait Version; C. D. Spielberger, R. L. Gorsuch, R. Lushene, P. R. Vagg, & G. A. Jacobs, 1983) as well as with indices of clinically significant change. Mixed models analysis of all randomized participants showed very large within-treatment effect sizes for both treatments (CI = [-.40, -.28], d = 1.86) with no significant differences at post (CI = [-.09, .07], d = .07) or 2-year follow-up (CI = [-.01, .01]), d = .12). There was also no statistical difference between compared treatments on clinically significant change based on chi-square analysis. Interpersonal and emotional processing techniques may not augment CBT for all GAD participants. Trial Registry name: Clinical Trials.gov, Identifier: NCT00951652.