1. Cognitive Behavioral Treatment of Generalized Anxiety Disorder
The original version of these slides was provided by
Michael W. Otto, Ph.D.
with support from NIMH Excellence in Training Award at the Center for Anxiety and Related Disorders
at Boston University
(R25 MH08478)

2. Use of this Slide Set
Presentation information is listed in the notes section below the slide (in PowerPoint normal viewing mode).
A bibliography for this slide set is provided below in the note section for this slide.
References are also provided in note sections for select subsequent slides.
Select References
Barlow, D.H., Rapee, R.M., & Brown, T.A. (1992). Behavioral treatment of generalized anxiety disorder. Behavior Therapy, 23,
Behar, E., DiMarco, I. D., Hekler, E.B., Mohlman, J., Staples, A.M. (2009). Current theoretical models of generalized anxiety disorder (GAD): conceptual review and treatment implications. Journal of Anxiety Disorders, 23,
Borkovec, T.D., Alcaine, O., & Behar, E. (2004). Avoidance theory of worry and generalized anxiety disorder. In R.G. Heimberg, C.L. Turk, & D.S. Mennin (Eds.), Generalized anxiety disorder: Advances in research and practice (pp ). New York: Guilford.
Borkovec, T.D., & Roemer, L. (1995). Perceived functions of worry among generalized anxiety disorder subjects: Distraction from more emotionally distressing topics? Journal of Behavior Therapy and Experimental Psychiatry, 26,
Borkovec, T.D., & Ruscio, A.M. (2001). Psychotherapy for generalized anxiety disorder. Journal of Clinical Psychiatry, 62,
Dugas, M.J., Ladouceur, R., Leger, E., Freeston, M.H., Langlois, F., Provencher, M.D., & Boisvert, J-M. (2003). Group cognitive-behavioral therapy for generalized anxiety disorder: Treatment outcome and long-term follow-up. Journal of Consulting and Clinical Psychology, 71,
Haby MM, Donnelly M, Corry J, Vos T (2006).Cognitive behavioural therapy for depression, panic disorder and generalized anxiety disorder: a meta-regression of factors that may predict outcome. Aust N Z J Psychiatry, 40, 9-19.
Heimberg RG, Turk CL, & Menin DS (Eds.), Generalized anxiety disorder: Advances in research and practice (pp ). New York: Guilford Press.
Mennin, D.S., Heimberg, R.G., Turk, C.L., & Fresco, D.M. (2005). Preliminary evidence for an emotion dysregulation model of generalized anxiety disorder. Behaviour Research and Therapy, 43,
Mitte K. (2005). Meta-analysis of cognitive-behavioral treatments for generalized anxiety disorder: a comparison with pharmacotherapy. Psychological Bulletin, 131,
Norton, P. J., & Proce, E. C. (2007). A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders. Journal of Nervous and Mental Diseases, 195,
Orsillo, S.M., Roemer, L., & Barlow, D.H. (2003). Integrating acceptance and mindfulness into existing cognitive-behavioral treatment for GAD: A case study. Cognitive & Behavioral Practice, 10,
Roemer, L., & Orsillo, S.M. (2002). Expanding our conceptualization of and treatment for generalized anxiety disorder: Integrating mindfulness/acceptance-based approaches with existing cognitive-behavioral models. Clinical Psychology: Science and Practice, 9,
Stewart, R. E., & Chambless, D. L. (2009). Cognitive-behavioral therapy for adult anxiety disorders in clinical practice: a meta-analysis of effectiveness studies. Journal of Consulting and Clinical Psychology, 77,
Wells, A. (1999). A cognitive model of generalized anxiety disorder. Behaviour Modification, 23,

3. Slide Set Outline Treatment outcome findings
Perspectives across meta analyses
Treatment models
Similarities (over differences)
Elements of treatment
What is accomplished in session
Future directions

4. Generalized Anxiety Disorder: Diagnostic Considerations
Pervasive worry and chronic arousal
Residual category of panic disorder in DSM-III
Spheres of worry in DSM-III-R and chronic arousal
Excessive and uncontrollable worry and 3 of 6 symptoms in DSM-IV
restless, keyed up, on edge
easily fatigued
difficulties concentrating
irritability
muscle tension
sleep disturbance

5. Core Patterns in GAD Uncontrollable worry Future orientation
Negative cognitive biases
Somatic arousal
Role and task inefficiency
Interpersonal aversiveness (unbalanced relationships)

6. GAD: Core Treatment Elements
Information
Applied Relaxation
Cognitive Restructuring (probability estimates, coping estimates)
Cue-Controlled Worry (worry times + problem solving)
Worry Exposure (including existential topics)
Mindfulness

7. Meta-Analyses: 5 Perspectives
All Randomized Trials (pre-post)
Norton & Price, 2007
Placebo-Controlled Trials (controlled effect size)
Hofmann & Smits, 2008
Elements of Treatment (controlled effect size)
Gould et al., 2004
Differential Efficacy (pre-post)
Siev & Chambless, 2007
Effectiveness Trials (pre-post)
Stewart & Chambless, 2009
This collection of meta-analyses provides different perspectives on the efficacy of CBT for GAD. Within-group effect sizes examine the magnitude of change from pre-treatment to post-treatment. Controlled effect sizes examine the magnitude of benefit of the identified treatment over a control condition. Hence, controlled effect sizes are often several magnitudes smaller than pre-post effect sizes. Both provide a perspective on treatment outcome, with controlled effect sizes providing a more conservative estimate of active treatment elements.

8. Meta-Analysis of Randomized Anxiety Trials of CBT (within ES)
Meta-Analysis of Randomized Anxiety Trials of CBT (within ES) Norton & Price, 2007, JNMD
Effect Size (d)
In this meta-analysis, the magnitude of pre-post treatment changes with CBT is seen relative to similar measures for other anxiety disorders (using only data from randomized treatment trials). From the perspective of this effect size analysis, treatment of GAD shows high responsivity (although these estimates include non-specific effects in treatment).
Source: Norton PJ, Price EC. A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders. J Nerv Ment Dis Jun;195(6):

9. Hofmann & Smits (2008) Meta-Analysis
Meta-analysis of well-controlled trials of CBT for anxiety
Inclusion criteria:
Random assignment to either CBT or placebo
The psychological placebo had to involve interventions to control for nonspecific factors (e.g., regular contact with a therapist, reasonable rationale for the intervention, discussions of the psychological problem)
A very different perspective is provided by the Hofmann & Smits meta-analysis that controls for non-specific treatment effects (by comparing outcomes to a placebo condition). In this analysis, two trials of GAD showed effect sizes somewhat less than the mean for CBT for other disorders.
These effects are illustrated over the next two slides.
Source: Hofmann SG, Smits JA. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry Apr;69(4):

11. Meta-Analysis of Controlled Trials of CBT (Between ES)
Meta-Analysis of Controlled Trials of CBT (Between ES) Hofmann & Smits, 2008, J Clin Psychiatry
Effect Size (g)

12. Gould et al., 2004 Meta-Analysis
16 studies
Mean drop-out rate 11.4%
Mean 10.1 hours of treatment
No difference in outcome for studies allowing stabilized medications
Maintenance of treatment gains across 6 months
In this somewhat dated meta-analysis, Gould and associates examined effect sizes in controlled trials. The mean duration of treatment was 10 hours, with a small drop-out rate (11%) indicating generally good tolerability of treatment. Anxiety and depressive symptoms appear to have benefitted equally in these treatment trials of GAD. The second part of the next slide shows that integrated CBT interventions (including anxiety management training; AMT) have particularly strong effect sizes relative to single-element interventions.
Source: Gould, R. A., Safren, S. A., Washington, D. O., & Otto, M. W. (2004). A meta-analytic review of cognitive-behavioral treatments. In R. G. Heimberg, C. L. Turk, & D. S. Menin (Eds.), Generalized anxiety disorder: Advances in research and practice (pp ). New York: Guilford Press.

13. Meta-Analysis of CBT – Gould et al., 2004 Between Groups
Effect Size (d)

14. Specificity of Treatment (Siev & Chambless, 2007, JCCP)
GAD CT = RT
Panic Disorder CT* > RT
Cognitive Therapy (CT) includes interoceptive exposure
Relaxation Therapy (RT)
Relaxation has traditionally done very well for GAD; better than it has for other anxiety disorders. This effect is shown nicely in an analysis by Siev & Chambless. Relaxation treatment appears to have more positive effects for GAD compared to panic disorder according to this analysis, suggesting that panic disorder requires greater treatment matching (specificity of treatment) than GAD.
Source: Siev J, Chambless DL. Specificity of treatment effects: cognitive therapy and relaxation for generalized anxiety and panic disorders. J Consult Clin Psychol Aug;75(4): Erratum in: J Consult Clin Psychol Oct;76(5): iii.

15. Meta-Analyses of Effectiveness Studies
Meta-Analyses of Effectiveness Studies (Within ES) (Stewart & Chambless, 2009, JCCP)
Effect Size (d)
This meta-analysis was directed at showing whether CBT generalized well from the clinical research setting to more real-world clinical settings. A total of 56 effectiveness studies of CBT for adult anxiety disorders were examined. In this investigation, the magnitude of benefit for GAD suffered more than that for other disorders (cf., the Norton & Price meta-analysis slide above), encouraging greater efforts at getting effective GAD treatments from the lab to the clinic setting.
Source: Stewart RE, Chambless DL. Cognitive-behavioral therapy for adult anxiety disorders in clinical practice: a meta-analysis of effectiveness studies. J Consult Clin Psychol Aug;77(4):

16. Comorbidity and Treatment (Newman et al., 2010)
76 treatment seeking adults with GAD
14 sessions of treatment
60.5% had comorbidity
Comorbid diagnosis linked to greater GAD severity at pretreatment
Greater change with treatment for those with comorbid depression, social anxiety disorder, specific phobia
Normal maintenance of treatment gains
Benefits to social anxiety disorder and specific phobia were maintained over 2 years, whereas benefits to depression were not
Disorder comorbidity is high in treatment seeking individuals with GAD. This study examined the impact of comorbidity on CBT for GAD. Those with comorbidity had greater GAD severity, but also achieved greater changes in symptoms. As has been found for other anxiety disorders, targeted treatment for one disorder also tends to improve other disorders. Overall, this study provides good news for the broad and powerful effects of CBT, despite the presence of comorbidity.
Source: Newman MG, Przeworski A, Fisher AJ, Borkovec TD. Diagnostic comorbidity in adults with generalized anxiety disorder: impact of comorbidity on psychotherapy outcome and impact of psychotherapy on comorbid diagnoses. Behav Ther Mar;41(1):59-72.

17. CBT Models of GAD (Behar et al., 2009, J Anx Dis)
Avoidance Model of Worry and GAD
(Borkovec, 1994; Borkovec et al., 2004)
Intolerance of Uncertainty Model
(Dugas et al., 1995; Freeston et al., 1994)
Metacognitive Model
(Wells, 1995)
Emotion Dysregulation Model
(Mennin et al., 2002)
Acceptance-Based Model of Generalized Anxiety Disorder
(Roemer & Orsillo, 2002, 2005)
There are a number of important models of GAD; aspects of these theories will be reviewed below.
Source for review: Behar, E., DiMarco, I. D., Hekler, E.B., Mohlman, J., Staples, A.M. (2009). Current theoretical models of generalized anxiety disorder (GAD): conceptual review and treatment implications. Journal of Anxiety Disorders, 23,

18. Wells (1999)
“Worry is a chain of catastrophising thoughts that are predominantly verbal. It consists of the contemplation of potentially dangerous situations and of personal coping strategies. It is intrusive and controllable although it is often experienced as uncontrollable. Worrying is associated with a motivation to prevent or avoid potential danger. Worry itself may be viewed as a coping strategy but can become the focus of …concern.”
Source: Wells, A. (1999). A cognitive model of generalized anxiety disorder. Behaviour Modification, 23,

19. Two Types of Worry (Dugas & Ladouceur, 2000)
Situations amenable to problem solving
Training in step-by-step problem solving
Situations that are not amenable to problem solving (hypothetical problems that never happen)
Worry times
Worry exposure
Using this distinction between two types of worry, Dugas and Ladouceur recommend problem solving training for the first type and interventions emphasizing worry time interventions or worry exposure (see below).
Source: Dugas MJ, Ladouceur R. Treatment of GAD. Targeting intolerance of uncertainty in two types of worry. Behav Modif Oct;24(5): see also 2000 paper in Cognitive and Behavioral Practice

20. Avoidance Function of Worry
Worry, a verbal process, inhibits vivid mental imagery and associated anxiety (Borkovec)
Evidence that it does attenuate:
somatic arousal at rest (Hoehn-Saric & McLeod, 1988; Hoehn-Saric, McLeod, & Zimmerli, 1989; Lyonfields, Borkovec, & Thayer, 1995; Thayer, Friedman, &Borkovec, 1996)
upon subsequent exposure to threat-related material (Borkovec & Hu, 1990; Peasley-Miklus & Vrana, 2000)
There are a wealth of psychopathology studies showing avoidance functions of worry.
Source:
Borkovec, T.D., Alcaine, O., & Behar, E. (2004). Avoidance theory of worry and
generalized anxiety disorder. In R.G. Heimberg, C.L. Turk, & D.S. Mennin
(Eds.), Generalized anxiety disorder: Advances in research and practice (pp. 77-
108). New York: Guilford.
Borkovec, T.D., & Hu, S. (1990). The effect of worry on cardiovascular response to
phobic imagery. Behaviour Research and Therapy, 28,
Borkovec, T.D., & Inz, J. (1990). The nature of worry in generalized anxiety disorder: A
predominance of thought activity. Behaviour Research and Therapy, 28,
Borkovec, T.D., & Roemer, L. (1995). Perceived functions of worry among generalized
anxiety disorder subjects: Distraction from more emotionally distressing topics? Journal of Behavior Therapy and Experimental Psychiatry, 26,
Hoehn-Saric, R., McLeod, D.R., & Zimmerli, W.D. (1989). Somatic manifestations in
women with generalized anxiety disorder: Physiological responses to
psychological stress. Archives of General Psychiatry, 46,
Thayer, J.F., Friedman, B.H., & Borkovec, T.D. (1996). Autonomic characteristics of
generalized anxiety disorder and worry. Biological Psychiatry, 39,

21. Worry and Conditioning
Non-clinical levels of worry are linked to greater conditionability
(Otto et al., 2008; Hermans et al., 2009)
Potential role for rumination in keeping
CS – UCS link alive
Studies investigating interpersonal differences that predict the degree to which new fears can be conditioned in the laboratory have identified worry proneness as an important variable; greater worry may lead to greater rehearsal of the CS – UCS linkage in de novo conditioning paradigms.
Source: Otto MW, Leyro TM, Christian K, Deveney CM, Reese H, Pollack MH, Orr SP. Prediction of "fear" acquisition in healthy control participants in a de novo fear-conditioning paradigm. Behav Modif Jan;31(1):32-51.
See also: Joos E, Vansteenwegen D, Hermans D. Post-acquisition repetitive thought in fear conditioning: An experimental investigation of the effect of CS-US-rehearsal. J Behav Ther Exp Psychiatry Jun;43(2):

22. Borkovec Encourage a present focus vs. future (past)
Leave patients expectancy free
Source:
Borkovec, T.D., Alcaine, O., & Behar, E. (2004). Avoidance theory of worry and
generalized anxiety disorder. In R.G. Heimberg, C.L. Turk, & D.S. Mennin
(Eds.), Generalized anxiety disorder: Advances in research and practice (pp. 77-
108). New York: Guilford.

23. Positive Beliefs About Worries
Worrying:
Is useful for finding solutions to problems
Is motivating – helps get things done
Is protective from negative emotions
Can prevent negative outcomes
Is a positive personality trait
(Francis & Dugas, 2004)
Source: Francis, K. & Dugas, M. J. (2004). Assessing positive beliefs about worry: Validation of a structured interview. Personality and Individual Differences, 37,

24. Negative Problem Orientation
Problems are threat to well-being
Doubt about problem-solving ability
Pessimism about problem solving outcome
Negative problem orientation is more specific to worry than depression in student samples, and is differentiated from neuroticism
(Robichaud & Dugas, 2005, BRAT)
Robichaud, M., & Dugas, M. J. (2005). Negative problem orientation (Part II): construct
validity and specificity to worry. Behaviour Research and Therapy, 43, 403–412.

25. Intolerance of Uncertainty
Motivates unnecessary worry-based planning
“What if X happens, could I cope by…”

26. All current models tend to underscore avoidance of internal experiences
Cognitive avoidance
Emotional avoidance
Intolerance of uncertainty
Negative cognitive reactions to emotions
Combined With
Positive beliefs about worry
While being concerned about effects of worry
This slide begins the process of integrating recent CBT models of GAD

27. Treatment Elements Borkovec
Awareness and self-monitoring
Relaxation
Cognitive therapy
Imagery rehearsal of coping strategies
(see Borkovec, 2006 for review)
Treatment elements for GAD as discussed by Borkoveck
Source: Borkovec, T. D. (2006). Applied relaxation and cognitive therapy for pathological worry and generalized anxiety disorder. In Davey, Graham C. L. (Ed.); Wells, Adrian (Ed.), Worry and its psychological disorders; Theory assessment and treatment. Wiley Publishing.

28. Treatment Elements Wells
Case formulation
Socialization to treatment
Modifying negative beliefs about the uncontrollability of worry
Modifying beliefs about the danger of worry
Modifying positive beliefs about worry
(Wells, 1999)
Source: Wells, A. (1999). A cognitive model of generalized anxiety disorder. Behaviour Modification, 23,

29. Treatment Elements Dugas et al.
Uncertainty recognition and behavioral exposure
Re-evaluation of the usefulness of worry
Problem-solving training
Imaginal exposure
(Dugas et al., 2003)
e.g., Dugas, M.J., Ladouceur, R., Leger, E., Freeston, M.H., Langlois, F., Provencher, M.D., & Boisvert, J-M. (2003). Group cognitive-behavioral therapy for generalized anxiety disorder: Treatment outcome and long-term follow-up. Journal of Consulting and Clinical Psychology, 71,

30. Relaxation Strategies
Progressive Relaxation (PR; e.g., Bernstein & Borkovec, 1973)
Applied Relaxation (AR;O¨ st, 1987).
AR does include exposure elements
As noted, relaxation treatment remains an intervention that is difficult to beat for GAD; it is simple, easy to disseminate, and fairly effective.

31. Mechanism of Relaxation Training (Ost, 1992)
Reduces general tension and anxiety (and link stressor/panic)
Enhances awareness about how anxiety works, de-mystifying and diminishing its impact
Enhances self-efficacy : individuals feel equipped to cope with anxiety

32. Relaxation Training Feel the difference between tension and relaxation
Tense 7 seconds, relax 15
Specific muscle groups to learn the procedure
Group them as skill increases
Use 10-second relaxation cue
Systematic muscle relaxation training uses a tense-relax method, where participants learn to discriminate tension and the act of relaxing, then repeat this skill. The use of a relaxation cue (the word “relax” said slowly) along with the relaxation procedure can aid the development of cue-controlled relaxation.

33. The “Words” of Worry Non-specific and hard to dispute
It will be horrible
It will be a disaster
Downward Arrow Techniques to clarify worries and put them in a form appropriate for cognitive-restructuring
Part of cognitive restructuring is attention to the type of words used in anxiety and in clarifying their presumed meaning in “downward arrow” (Socratic) questioning (e.g., And tell me what you mean by horrible? And tell me what is concerning about that? And what about that is most concerning for you?).

34. Cognitive Restructuring
Self monitoring
Logical analysis
Probability overestimations
Overestimations of the degree of catastrophe
Ability to cope
Like cognitive restructuring for other anxiety disorders, cognitive restructuring for GAD focuses on two classic distortions: (1) Overestimation of the probability of negative outcomes, and (2) Overestimations of the degree of catastrophe of outcomes (underestimations of the ability to cope with these potential outcomes). In GAD treatment, as patients learn to identify the role of thoughts in the worry cycle, the next steps are to help them intervene to (1) change their willingness to believe the negative predictions they are making, and (2) to help them generate and test alternative interpretations, with the goal of increasing their repertoire of more adaptive cognitive responses.

35. Relapse Prevention in Depression - Metacognitive Awareness
Classic CT and mindfulness-based CT both enhance metacognitive awareness
Level of metacognitive awareness is linked to relapse
Changing the relationship people have to their thoughts, rather than changing beliefs, may be important for preventing relapse
(Teasdale et al., 2002)
An example from the depression literature: One value of cognitive restructuring may not be to eliminate negative thoughts but to change the relationship people have with their automatic thoughts – developing a more dispassionate stance with respect to their thoughts. Study indicates that this metacognitive awareness is associated with protection from relapse in cognitive and mindfulness-based treatments for major depression.
Source: Teasdale JD, Moore RG, Hayhurst H, Pope M, Williams S, Segal ZV. Metacognitive awareness and prevention of relapse in depression: empirical evidence. J Consult Clin Psychol Apr;70(2):

36. Mindfulness –
Curious attention to the present moment, in an open, nonjudgmental, and accepting manner
(Bishop et al., 2004; Germer, 2005; Kabat-Zinn, 1994)
Mindfulness – a definition drawn from leaders in the field

37. Why Mindfulness? Hayes and Feldman, 2004 Roemer et al, 2009
Mindfulness training may enhance emotional regulation by addressing the patterns of over-engagement (e.g., rumination) and under-engagement (avoidance) that characterizes the disorder.
Target is a healthy level of engagement that “allows clarity and functional use of emotional responses”
Roemer et al, 2009
Non-clinical symptoms and clinical GAD status linked to lower mindfulness
Early support for mindfulness interventions in GAD
Source: Hayes AM & Feldman G. (2004). Clarifying the construct of mindfulness in the context of emotional regulation and the process of change in therapy. Clinical Psychology: Science and Practice, 11,
Roemer L, Lee JK, Salters-Pedneault K, Erisman SM, Orsillo SM, Mennin DS. Mindfulness and emotion regulation difficulties in generalized anxiety disorder: preliminary evidence for independent and overlapping contributions. Behav Ther Jun;40(2):

38. Worry Time Save up the worry (cue specificity)
End of the day worry time
In office (non-fun) setting
45 min – with writing
10 min – relaxation skills
Go have fun
Worry time is a classic intervention to help individuals gain control over their worry. With the worry time intervention, patients are asked to save all of their worries for a specific worry time each day. During worry time patients are to write out their primary concerns, then allow themselves to think constructively about the worry for approximately 45 minutes. Clinicians may instruct patients to end worry time with relaxation practice and then “save up” their worries for the next 23 hours until the next worry time. Because one goal of worry time is to constrain the environmental and time cues for worry, the worry time assignments should occur outside the bedroom and family room, and should preferably occur at a desk in a room or space reserved for work tasks.

39. GAD: Worry Exposure
Metaphor: Like watching a scary movie over and over – decreased arousal and changed meaning of the worry
Apply exposure plus response prevention (including the use of tape loops)
The goal is elimination of the worry response via repeated exposure to core fears
This technique should also be coupled with the prescription to worry through one topic and not switch among “spheres of worry”
Exposure interventions in generalized anxiety disorder involve helping patients learn to tolerate the increased autonomic arousal that accompanies visual imagery of feared outcomes, rather than engaging in worry to attenuate this emotional response.

40. GAD: Training in Normal Thinking
Teach “normal thinking” as alternative behavior. What does one think about when not preoccupied with worry?
Mindfulness of thinking states that are different from worry (e.g. daydreaming, experiencing, planning, enjoying)
Sensory awareness training
“Staying in the moment”
Use of “worry times”
Limited effects of exposure on valence/preference
As reflected by the positive psychology movement, reductions in pathological patterns are not necessarily the same as promotion of adaptive patterns. This slide attends to this reality by discussing the importance of helping patients with GAD develop normal thinking patterns.

41. Attention ModificationTraining - GAD
29 treatment seeking patients
Random assignment (train away vs. no train threat words)
8 sessions over 4 weeks
Goal:
Change attentional bias
Change GAD symptoms
Succeeded with both
Between group effect size of .80
Least efficacy on worry
(Amir et al., 2009, J Abn Psych)
New data is emerging on the potential power of attention training using dot-probe methodology. By changing vigilance to negative stimuli, there appears to be broad treatment effects. For example, Amir and associates examined an 8-session attention modification training program designed to decrease attention bias to threat cues and to reduce symptoms of GAD.
Source: Amir N, Beard C, Burns M, Bomyea J. Attention modification program in individuals with generalized anxiety disorder. J Abnorm Psychol Feb;118(1):28-33.

42. Attention Modification Training - GAD
Randomized clinical trial GAD (N = 29)
Stimuli: threatening or neutral words
50% of those in the active attention modification program were classified as responders (no longer meeting DSM diagnosis for GAD) vs. 13% in the control condition
(Amir et al., 2009)

43. New Directions Attentional training
Mindfulness/emotional tolerance training
Interoceptive exposure
Integrative treatment

44. GAD Interpersonal Roles
Polarizing the relationship: the worry partner
Improving couple’s problem-solving
Relationship interventions may also need to be applied for some patients with GAD, given the polarizing role of worry in relationships and the importance of establishing adaptive patterns for problem solving.

45. Conclusions Nice convergence of strategies in the field
Need to convincingly beat relaxation training as a first step in care
Need to confirm resilience of treatment to depression (but emergent finding across anxiety disorders)
Room for improvement – to achieve high end-state functioning