Cognitive-Behavioral Treatment of Generalized Anxiety Disorder

Michelle G. Newman, Ph.D. and Thomas 0 Borkovec, Ph.D.

Penn State University

I. Description of Treatment any subtle shift in their anxiety level and to note
interactive patterns of worrisome thinking,
Cognitive behavioral therapy (CBT) of catastrophic imagery, physiological activity,
generalized anxiety disorder (GAD) is based on the behavioral avoidance, and the external cues that may
theory that the disorder sterns from constant trigger these responses. As clients become aware of
perceptions of the world as a dangerous place, their anxiety cues, they are encouraged to intervene as
resulting in a process of maladaptive and habitual early as possible, using newly learned coping
interactions among cognitive, behavioral, and responses.
physiological response systems. Maladaptive The early replacement of maladaptive
cognitive responses include a pre-attentive bias to' responses with more adaptive ones creates two
threat cues (Mathews, 1990), negatively valenced benefits. First, because the anxiety spiral is weaker at
images and worrisome thinking (Borkovec & Inz, its initiation, coping responses have a greater chance
1990), and cognitive avoidance of some aspects of of reducing the anxiety and of preventing its continued
anxious experience (Borkovec, Shadick, & Hopkins, intensification. Second, each time the spiral occurs,
1991). Maladaptive behavioral responses include its sequence of interacting responses is strengthened in
subtle behavioral avoidance (Butler, Fennel, Robson, memory. Therefore, early substitution of adaptive
& Gelder, 1991) and slowed decision-making responses for maladaptive ones precludes such
(Metzger et. al., 1990). The physiological responses strengthening and instead reinforces adaptive coping
entail excessive muscle tension and an autonomic sequences. As clients learn to employ adaptive
inflexibility based on a deficiency in parasympathetic responses to previously identified internal and ex1emal
tone (Thayer, Friedman, & Borkovec, 1995). The triggers~ the triggers lose their threatening meaning
interaction of these maladaptive response systems and become discriminative stimuli for deployment of
leads to a process of spiraling intensification in effective coping methods.
anxiety. CBT attempts to replace these maladaptive Adaptive coping interventions include
reactions with multiple adaptive coping responses that relaxation training, self-control desensitization, and
target each domain of dysfunction. cognitive restructuring. Within these interventions,
Foundational to this treatment is client self- clients are taught multiple techniques. This allows the
monitoring. Clients are encouraged to pay attention to client to experiment with a variety of strategies to

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The Clinical Psychologist Volume 48, Number 4, Fall 1995

determine what works best for them and helps to In addition to showing statistically significant
establish flexible choices to combat previous rigid improvement, CBT has also demonstrated clinically
modes of responding. Relaxation techniques, significant improvement. In 3 of the 4 interpretable
including pleasant imagery, slowed paced studies which have assessed clinically significant
diaphragmatic breathing, progressive muscle change, CBT showed long-term maintenance or
relaxation, differential relaxation, meditation, and cue- further gains in clinically significant change
controlled relaxation are taught within an applied. (Borkovec & Whisman, in press). However, despite
relaxation framework (Ost, 1987). Clients are also demonstration of efficacy, only about half of CBT-
trained in Goldfrieds' (1971) self-control treated clients achieve high end-state functioning.
desensitization to provide frequent rehearsals of the Thus, further technique development is necessary.
application of relaxation skills to eliminate imagery-
induced anxiety cues and worrisome thinking. III. Clinical References
Cognitive therapy techniques include identification of
automatic thoughts and cbre beliefs, logical analysis Craske, M.G., Barlow, D.H., & O'Leary, T. (1992)
based on probability and evidence, development of Mastery of your anxiety and wovy. Graywind
Publications Incorporated;
multiple alternative perspectives, behavioral testing of
Beck, A.T., & Emery, G. (1985). Anxiety disorders and
predictions, and decatastrophizing (Beck & Emery,
phobias: A cognitive perspective. New York:
1985). Cognitive products from these interventions Basic Books.
are then used in self-control desensitization to provide Goldfried, M.R. & Davison, G.C. (1969). Clinical
frequeIit practice in shifting to adaptive perspectives in behavior therapy, New York: Holt, Rinehart
response to incipient anxiety cues. Homework and Winston Incorporated
assignments aim at encouraging frequent applications Smith, J.C. (1985). Relaxation dynamics: Nine world
of all of the techniques to increasingly early detections approaches to self-relaxation. Champagne,
of anxious responding. lllinois: Research Press.

II. Summary of Studies Supporting the IV. Resources for Training

Treatment's Efficacy
In a meta-analysis of the extant contrblIed
outcome studies, Borko'vec and Whisman (in press)
found that CBT for GAD produces significant
improvement which is maintained for up to one year
following treatment termination. CBT has also been
found to generate greater improvement than nO
treatment, analytIc psychotherapy, pill placebo,
nondirective therapy, and placebo therapy (Borkovec
& Whisman, in press; Durham et. al~, 1994).
Although several investigations have not found
differences between CBT and either cognitive therapy
or behavior therapy alone, others have documented its
superiority immediately after treatment or at long-term
follow-up, and meta-analysis of studies using common
outcome measures indicates that CBT produces the
largest effect sizes when compared to other therapy
and control conditions (Borkovec & Whisman, in
press). CBT is also well liked by clients and is
associated with relatively low drop-out rates and
significant reductions in the need for an.xiolytic
medication.
There are future plans to establish training in
cognitive behavioral therapy of GAD at Graywind
Publications at Executive Park Drive, Albany, N.Y.
12203. (518) 438-3231.
V. References
Botkovec, T.D., & InZ, 1. (1990). The nature of worry in
generaiiZecianxiety disorder: A predominance
oftho\iiht activity. Behaviour Research and
Therapy, ~ 153..158.
Bbrkovec,T.D. & Whisman, M.A. (in press).
Psychosocial treatment for generalized anxiety
disorder. In M. Mavissakalian &R Prien
(Eds.), Anxiety disorders: Psychological and
pharmacological treatments. Washington,
D.C.: American Psychiatric Press.
Borkovec, T.D., Shadick, R., & Hopkins, M. (1991).
The nature of normal and pathological worry.
In R.M. Rapee & D.H. Barlow (Eels.), Chromc
anxiety, generalized anxiety disorder, and
mixed anxiety depression. New York:
Guilford Press, 29-51.

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The CRnical Psychologist
Butler, G., Fennel, M., Robson, P., & Gelder, M.
(1991). Comparison of behavior therapy and
cognitive behavior therapy in the treatment of
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Consulting and Clinical Psychology, i2. 167-
175.
Durham, R.C., Murphy, T., Allan, T., Richard, K.,
Treliving, L.R., & Fenton, G.W. (1994).
Cognitive therapy, analytic psychotherapy, and
anxiety management training for generalised
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165,315-323.
Goldfried, M.R. (1971). Systematic desensitization as
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Mathews, A. (1990). Why worry? The cognitive function
of anxiety. Behavior Research and TherapY.
ll.455~68.
Metzger, R.t., Miller, M., Cohen, M., Soflca, M, &
Borkovec, T.D. (1990). Worry changes in
decision-making: The effect of negative
thoughts on cognitive processing. Journal of
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Ost, L. (1987). Applied relaxation: Description of
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Thayer, J.F., Friedman, B.H., & Borkovec, T.n.. (1995).
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