Cognitive Behavioral Treatment of Generalized Anxiety Disorder

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Journal of Contemporary Psychotherapy [jcp]
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Style file version Nov. 19th, 1999
Journal of Contemporary Psychotherapy, Vol. 30, No. 2, 2000
Cognitive-Behavioral Treatment of Generalized

Anxiety Disorder
James C. Overholser and Elizabeth H. Nasser
Generalized Anxiety Disorder (GAD) can be treated effectively with cognitivebehavioral therapy. When working with clients who have GAD, therapy can focus
on four central areas that help to promote therapeutic change. The initial focus
of therapy is on developing a sound therapeutic alliance and educating the client
about anxiety symptoms. Skills training focuses on relaxation training and cognitive changes that can help clients confront their worries in a constructive manner.
Then, exposure to internal and external aspects of the anxiety can help clients
test and refine their coping skills. Finally, because of the chronic nature of GAD,
relapse prevention strategies can be used to help maintain treatment gains over
time. These strategies allow a broad but flexible treatment plan that can be adapted
to the unique needs of each individual client.
KEY WORDS: Cognitive; behavioral; therapy; generalized; anxiety.
Generalized Anxiety Disorder (GAD) is characterized by excessive worry

over minor issues. The central features of GAD are excessive anxiety and worry of
at least six month duration that the individual finds difficult to control (American
Psychiatric Association, 1994). The anxiety and worry are associated with feelings of tension or restlessness, fatigability, concentration difficulties, irritability,
muscle tension, and sleep disturbance. Clients with GAD tend to worry about
many different things, they view their worry as unrealistic, and they experience
their worry as uncontrollable (Sanderson & Barlow, 1990). Many patients with
GAD report a chronic course (Rickels & Schweizer, 1990) with lifelong anxiety
(Akiskal, 1985).
GAD can be treated effectively with cognitive-behavioral therapy (Barlow
et al., 1984). A review of published research (Chambless & Gillis, 1993) found
Address correspondence to James C. Overholser, Ph.D., Department of Psychology, Case Western
Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-7123.
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Overholser and Nasser
that cognitive-behavioral therapy for GAD is substantially more effective than

waiting list, nondirective therapy, or pill placebo. Furthermore, a meta-analysis
of 61 studies involving treatment of GAD (Gould, Otto, Pollack, & Yap, 1997)
found cognitive-behavioral therapy to be as effective as pharmacological treatment
in reducing symptoms of anxiety. In addition, cognitive-behavioral therapy was
associated with greater maintenance of treatment gains over time and stronger
reductions in comorbid depression.
Butler, Cullington, Hibbert, Klimes, and Gelder (1987) evaluated the treatment of GAD in 22 patients who were given cognitive-behavioral treatment compared to 23 patients assigned to a waiting-list control group. Cognitive-behavioral
treatment included relaxation training, calming self-statements, and exposure to
the feared situations. Cognitive-behavioral therapy was brief, typically lasting
less than ten sessions. Nonetheless, therapy had significant and lasting effects.
Cognitive-behavioral therapy produced significant change on all measures of anxiety and depression, while clients on the waiting-list showed only slight reductions
in symptoms. The beneficial effects of treatment were then replicated when the
waiting-list subjects were provided cognitive-behavioral therapy. At the conclusion
of treatment, half of the patients had scored within normal limits on a self-report
measure of anxiety. The effects of treatment were maintained at the six-month
follow-up assessment.
In a study conducted by Barlow, Rapee, and Brown (1992), 65 patients with
GAD were randomly assigned to three treatment groups: applied muscle relaxation,
cognitive restructuring, or a combination of relaxation and cognitive restructuring.
No significant differences were found across the three treatments. At the conclusion
of treatment, 63% of the relaxation group, 67% of the cognitive therapy group
and 36% of the combined group were considered treatment responders. All three
treatments were significantly better than a waiting list control group, which showed
no improvement over time. Reductions in anxiety were maintained over a two-year
follow-up period. In addition, the use of anxiolytic medication was reduced over
the follow-up period.
The present manuscript describes a concise, integrated model of treatment
for adult psychiatric outpatients diagnosed with GAD. Cognitive-behavioral therapy for GAD includes four central components: initial preparation for therapy,
training in generic coping skills, exposure to the stimuli that elicit fear and worry,
and relapse prevention. Different clients need different amounts of time to make
progress in these four areas. Also, these components can be addressed simultaneously rather than sequentially. Each of these components will be described, and
clinical examples will be provided.
INITIAL PREPARATION FOR THERAPY
At the start of therapy, clients often experience high levels of emotional distress. The therapist must use this distress as the motivational force that encourages
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clients to work toward therapeutic change. The therapist should keep in mind three
basic goals of the initial therapy sessions: establish a therapeutic alliance, educate
the client about anxiety and its treatment, and conduct a thorough assessment of
the clients strengths and weaknesses.
During the early therapy sessions, it is essential to establish a good therapeutic relationship with the client (Overholser & Silverman, 1998). Because of
the persistent feelings of anxiety and insecurity, clients with GAD need to feel
that they can trust the expertise of their therapist. Also, clients with GAD benefit from a supportive relationship that provides a calming reassurance, especially
during the early stages of therapy. A nondirective, supportive relationship with the
therapist can produce significant reductions in GAD symptoms (Stanley, Beck, &
Glassco, 1996). However, the benefits from a nondirective, supportive therapeutic
relationship alone appear to be short-lived (Borkovec & Costello, 1993). Nonetheless, a strong therapeutic relationship provides the foundation needed for more
challenging work.
Many clients gain some reassurance through brief educational explanations
about anxiety and its treatment. Clients can learn about fight or flight reactions
in order to normalize the physiological basis of anxiety. The therapist may provide
outside reading to help clients learn about their anxiety. The use of written materials
explaining the nature of anxiety has proved to be an important aspect of treatment,
particularly among elderly patients (McCarthy, Katz, & Foa, 1990). Also, elderly
clients may benefit from the increased use of handouts and greater explanation
of treatment rationales (King & Barrowclough, 1991). Patients in group therapy
for GAD have reported the most useful aspects of the therapeutic experience
to be receiving information about anxiety and stress and interacting with other
individuals dealing with similar problems (Powell, 1987).
During the early stages of treatment, the therapist should conduct a thorough
biopsychosocial assessment of the clients problems. GAD can be influenced by
biological factors, psychological factors, and social factors. Some clients should be
referred for a medical evaluation to rule out physical illness or drug reactions as
possible causes of the anxiety. Symptoms of anxiety can often be found in patients
who have hypertension (Paterniti et al., 1999), coronary artery disease (Kubzansky,
Kawachi, Weiss, & Sparrow, 1998), or thyroid problems (Noyes et al., 1992).
There are a number of factors that hinder the accurate diagnosis of GAD
(Palmer, Jeste & Sheikh, 1997). The diagnosis of GAD is complicated by the
overlap in symptoms between GAD and depressive disorders. Several of the diagnostic criteria for GAD (fatigability, concentration, sleep disturbance, and restlessness) are also diagnostic criteria for a depressive disorder (American Psychiatric
Association, 1994). When the DSM-IV associated symptom criteria for GAD require at least 4 of 6 symptoms, the specificity of the GAD diagnosis improves
significantly (Brown, Marten & Barlow, 1995).
The intake evaluation can be guided by semi-structured interview measures.
The Anxiety Disorders Interview Schedule (ADIS: Brown, DiNardo, & Barlow,
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1994; DiNardo & Barlow, 1987) is a structured interview designed to evaluate

anxiety disorders, mood disorders, somatoform disorders, substance use disorders,
psychotic disorders and medical problems. The ADIS can help guide the intake
evaluation and diagnosis.
Therapists may use several standardized questionnaires to assess the clients
initial level of anxiety. These forms may be re-administered over the course of
therapy to monitor the clients progress. The Generalized Anxiety Disorder Questionnaire (Roemer, Borkovec, Posa, & Borkovec, 1995) is a self-report diagnostic
instrument that has been found to correlate highly (80%) with interview measures
of GAD. The Penn State Worry Questionnaire (PSWQ: Meyer et al., 1990) is a
self-report questionnaire which has shown utility in the differential diagnosis of
GAD. The PSWQ includes 16 items assessing the tendency to worry, such as I am
always worrying about something and Once I start worrying I cannot stop. Other
self-report questionnaires including the Worry Domains Questionnaire (Tallis,
Eysenck, & Mathers, 1992) which measures general worry themes, the Worry
Scale (Wisocki, Handen, & Morse, 1986) which was specifically designed to assess the unique features of worry in elders, and the State-Trait Anxiety Inventory
(Spielberger, 1989) which is useful for measuring the degree of trait anxiety. The
Intolerance of Uncertainty Questionnaire (Freeston et al., 1994) contains items
about uncertainty, emotional and behavioral reactions to ambiguous situations.
Self-monitoring can be used to help clients assess and understand their symptoms of anxiety (see Fig. 1). When clients are asked about the frequency of their
anxiety, most GAD clients report feeling anxious all the time. However, such
retrospective reports are rarely accurate. Ongoing self-monitoring can help clients
Fig. 1. Self-monitoring form for tracking symptoms of generalized anxiety.
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to identify periods throughout their week when they feel relaxed, or at least somewhat calm. Therapy can focus on identifying the cognitive and situational factors
associated with these calm periods, and working to increase their frequency or
duration over time.
Clients can be instructed to rate their feelings using the Subjective Units of
Discomfort Scale (SUDS: Wolpe & Lazarus, 1966). Scores provide a global rating
of anxiety, ranging from 0 (i.e., totally calm and relaxed) to 100 (i.e., extremely
tense, nervous, and worried). A thorough assessment, including self-monitoring
of daily changes in anxiety levels, can reveal a mixture of factors that tend to
elicit the anxiety. These precipitating factors can include being left home alone,
dealing with a sick child, a spouse leaving for a business trip, or paying bills that
elicit financial worries. As clients learn to rate their subjective experience during
therapy sessions, they can learn that even when they feel uncomfortable, their level
of anxiety is usually only mild-to-moderate. Also, as clients use the same rating
throughout their week as part of the self-monitoring, they can begin to identify
patterns in symptoms over days and across events. For example, an adult female
client with GAD initially reported feeling high levels of anxiety all the time.
After two weeks of self-monitoring, she was able to appreciate that her usual
level of anxiety was in the mild range (SUDS scores from 2040), with a few
bursts of more intense feelings. Also, it became easy to see that her highest levels
of anxiety usually occurred either when she was home alone, or shortly after an
argument with her husband. Self-monitoring helped to direct the focus of therapy
onto relationship issues and matters of independence.
TRAINING IN COPING SKILLS
After the initial evaluation has been completed, therapy can focus on helping
clients develop new coping skills for managing their anxiety and worry. Many
clients with GAD can benefit from a wide range of pro-active coping skills. Clients
can learn to appreciate the value of coping with problems in a direct manner. As
they cultivate these coping skills, their confidence grows, and it becomes easier
for them to approach instead of avoid their worrisome situations. Several coping
strategies have been used widely in cognitive behavioral therapy. These include
relaxation training, cognitive restructuring, and coping self-statements.
Relaxation training can be used as a generic coping skill (Overholser, 1990)
and can be an effective tool in the treatment of GAD (Borkovec & Costello, 1993).
Relaxation training can help clients reduce their general feelings of anxiety and
tension and helps when they are about to confront a difficult situation (Coleman &
Gantman, 1989). Clients can be taught progressive relaxation training (Bernstein
& Borkovec, 1973) or passive relaxation training (Overholser, 1990) with guided
imagery (Overholser, 1991) in order to manage their feelings of anxiety. The
amount of session time spent on relaxation training can be kept short, with much
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of the training being conducted by the client as part of regular assignments to be

completed between sessions.
Cognitive therapy can help to provide more lasting changes than those obtained by purely behavioral therapy alone (Borkovec & Costello, 1993; Durham &
Turvey, 1987). The main benefits of a cognitive approach include helping clients
learn strategies for managing difficult situations, learning new ways to look at
common problems, and learning to stop anxiety from spiraling out of control
(Durham et al., 1999). Clients with GAD often focus their worries on their own
health and safety, the health and safety of family members, job stability, financial
security, interpersonal conflict, and other minor matters (Breitholtz, Johansson, &
Ost, 1999).
Cognitive interventions that are designed to address pervasive worrying and
catastrophic thinking may be particularly effective with clients who have GAD
(Borkovec & Costello, 1993; Borkovec et al., 1987). Anxiety is based on perceptions of unpredictability, uncontrollability, and danger (Zinbarg, Craske, &
Barlow, 1993). Clients may evaluate common stressors as terrible, unbearable
or catastrophic rather than merely uncomfortable or unfortunate (Zinbarg
et al., 1993). Socratic questioning (Overholser, 1993) and hypothesis testing can be
used to help clients re-evaluate flawed and illogical beliefs about worrying (Dugas
et al., 1998). In addition, GAD clients can learn to stay focused on problemsolving rather than becoming distracted by minor details. For example, an adult
female client with GAD reported frequent worries over minor mishaps at work. She
would ruminate over possible mistakes, and frequently feared that she would be
fired because of a silly comment or a minor error she made on the job. Her natural
cognitions (e.g., Did I act too rashly?; Im so confused about what to do; I feel
terrible about how things went today) tended to exacerbate her anxiety. In therapy,
she learned to refocus on the positive aspects of her performance, and use helpful
reminders to manage her anxiety (e.g., Dont make things worse than they are;
Do your best and thats good enough). Also, clients can learn to differentiate immediate problems from remote possibilities to improve effective problem-solving.
Finally, cognitive exposure may be used to address cognitive avoidance so that
uncertain future events will become less threatening and the need for avoidance
will diminish.
Clients with GAD tend to overestimate the advantages (Ladouceur et al.,
1998) and underestimate the disadvantages of worrying (Brown et al., 1998). GAD
patients often report that worrying is purposeful, either as a means of preparing
for the worst (Ladouceur et al., 1998) or as a means of distraction from more
emotionally distressing topics (Borkovec & Roemer, 1995). Further, worry may
be used to avoid imagining feared events and avoid the resulting physiological
arousal (Borkovec et al., 1991).
Therapy can focus on developing coping self-statements to help clients
manage their anxiety. A stress inoculation training model (Meichenbaum &
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Deffenbacher, 1988) can help clients learn to focus on their self-statements that
occur before, during, and after confronting a distressing event. Clients can be asked
to write a list of useful self-statements, emphasizing that all statements should be
honest and positive. Self-statements can be used to develop a sense of control
over problems and emotional reactions. A central tenet of cognitive restructuring
involves enhancing the perception of safety (Zinbarg et al., 1993). For example,
an adult female client with GAD experienced numerous worries about the physical health of her oldest son. He was seven years-old and suffered from asthma.
Although his illness was not severe, he often experienced moderate difficulties
with his breathing. On several occasions, he needed emergency medical treatment
for his asthma. The client reported frequent images of her son during an imagined
medical catastrophe. Her frequent worries made it difficult for her to manage
minor asthmatic problems without overreacting. During therapy, she learned to
redirect her worry into constructive planning, and guided herself with coping selfstatements, such as I can deal with this situation; If I stay calm, everything will
be okay; Getting myself upset will not help me here; Stay focused and do
something to make things better. She noticed that these self-statements helped to
circumvent her anxiety from spiraling out of control. Her ability to manage the
situation improved and thereby reduced her anxiety.
Therapy can help clients learn to generate alternative explanations for events
and reduce the tendency to castrophize (Stanley et al., 1996). Clients need to see
that many of their worries are unrealistic or unproductive (Andrews, Crino, Hunt,
Lampe, & Page, 1994). For example, an adult male client with GAD reported
continuous irrational worries about being fired from his job. He had received
positive evaluations at work, but he was afraid that he would be fired any time.
He believed that others evaluated his work performance in a negative manner.
He had difficulties tolerating the perceived uncertainty of his job status, and his
frequent worries were disrupting his ability to work. In therapy, the client learned
that his worry was related to his perfectionistic attitudes and frequent negative selfevaluations. When the client learned to examine his performance in a positive but
realistic manner, he was able to control his worry and reduce his catastrophic fears.
Because GAD may be related to early experiences with uncontrollable events,
intolerance of uncertainty and perceived uncontrollability often play central roles
in GAD (Chorpita & Barlow, 1998). Therapy may need to confront the realistic
probability of feared outcomes actually occurring. Clients need to evaluate the evidence underlying their fears (Coleman & Gantman, 1989). Negative expectations
can be reframed as hypotheses or interpretations to be examined logically (Zinbarg
et al., 1993).
When clients constantly worry about family and money problems, their inability to cope with these problems confirms their feelings of low self worth (Warren
& Zgourides, 1991). Because social evaluative fears can be pervasive and may
become self-fulfilling, clients with GAD may face daily threats to the adequacy of
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future performance, circumstances and self concept (Borkovec, et al., 1991). Perceived failures in these areas may serve to reduce self-esteem even further. Some
treatments have incorporated self-esteem and self-confidence enhancement into
the treatment of GAD (Butler et al., 1987, 1991), helping clients to appreciate how
a lack of confidence may have impaired their ability to cope with certain tasks.
EXPOSURE TO INTERNAL AND EXTERNAL PRECIPITANTS
Most clients with anxiety disorders can be treated through various forms
of exposure therapy (DiFilippo & Overholser, 1999; Overholser, 1995, 1999a,
199b). However, GAD poses certain complications not seen with other anxiety
disorders. Historically, GAD was thought to be difficult to treat due to the diffuse,
nonspecific anxiety unrelated to any specific situational triggers. Moreover, many
minor, common daily situations can serve as potential triggers that elicit the anxiety
reactions and can become targets for treatment. In addition, therapist and client
may be able to identify and confront common anxiety-based themes, such as
perceptions of personal vulnerability. Therapy may uncover core beliefs that clients
hold about self, other people, and the world (White, 1999). Many aspects of GAD
involve state-dependent negative cognitions that are more prevalent during periods
of anxiety (Zinbarg et al., 1993). Exposure therapy allows therapist and client to
confront these unrealistic interpretations and pessimistic expectations.
A central problem in anxiety disorders is the cognitive process in which
events are perceived as dangerous (Beck & Emery, 1985). Negative thoughts and
images can trigger the behavioral, physiological and affective reactions of anxiety.
Clients may reason that their subjective experience of anxiety is evidence that
danger exists (Arntz, Rauner, & Van Den Hout, 1995). However, such emotional
reasoning will prevent clients from recognizing false alarms (Arntz et al., 1995).
The tendency to process information via emotional reasoning may predispose
clients toward the development of anxiety disorders (Arntz et al., 1995). Treatment
requires testing danger expectations against reality. During exposure sessions,
clients need to focus on objective information about safety and danger rather than
attending to the subjective experience of anxiety (Arntz et al., 1995).
Imaginal exposure can be conducted during therapy sessions (Borkovec &
Costello, 1993; Stanley et al., 1996). The client can be asked to imagine a specific
event that might involve exposing oneself or a loved one to a risk of physical injury
or impaired health. Then, therapist and client can work to understand and change
the cognitive and somatic reactions that follow. For example, an adult female client
with GAD reported frequent worries about the safety of her husband. He worked
in law enforcement, and he often had erratic work hours. In therapy, the client was
asked to imagine that her husband had not arrived home after work, and he was
now several hours late. She had not heard from him, and she was unable to reach
him by telephone. This scenario quickly elicited catastrophic fears in the client.
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She described graphic images of her husband being injured in a car accident or
shot and robbed on the streets of the inner city. However, when she was able to
discuss the realistic possibility of these events, she could reduce some of her fear.
Nonetheless, once these images were elicited, they were hard to erase from her
mind. In addition, she revealed some minor superstitious beliefs, such that she
viewed her own worrying as a protective factor that could reduce the likelihood
that her husband would actually be injured. She feared that if she did not worry,
then she would be unprepared and completely devastated when she was informed
of her husbands accident.
In vivo exposure involves therapist and client leaving the therapy office and
working in the clients natural environment. Exposure therapy requires clients to
reduce their reliance on safety behaviors, such as the use of frequent telephone
calls to verify the safety of a loved one (White, 1999). In vivo exposure can be
conducted as part of behavioral assignments completed by the client between
sessions. For many clients with GAD, worry is elicited by numerous minor events
that occur during the typical week. Clients can be asked to expect and prepare for
these minor mishaps. For example, an adult female client with GAD was asked
to record times during the week when she felt calm versus worried. When she
experienced a high degree of anxiety, she was asked to write a paragraph about
her subjective experience. She was explicitly instructed not to try to reduce her
anxiety. Instead, she was told that the experience of anxiety was important for
her therapy because it allowed access to the cognitive and somatic changes that
occur during her worry times. After two weeks of performing this simple task, the
client was able to distance herself from the acute experience, reduce her feelings of
apprehension, and appreciate the trivial nature of most of her worries. She learned
that she could confront many events without being overwhelmed by anxiety.
RELAPSE PREVENTION
Because of the chronic nature of GAD, is it important for the therapist to plan
for long-term management concerns (Rickels & Schweizer, 1990). After clients
have made successful changes in their coping style and have confronted common
problems via exposure therapy, relapse prevention strategies can help to ensure that
the changes are maintained over time. However, this does not necessarily imply that
relapse prevention strategies are saved until the end of therapy. Relapse prevention
must be interlaced with the development of coping strategies. As applied to the
treatment of GAD, relapse prevention includes identifying and confronting problem situations, strengthening coping skills, and preparing for temporary set-backs.
Cognitive changes seem essential for promoting durable improvements
(Borkovec & Costello, 1993; Durham & Turvey, 1987). Cognitive and perceptual changes appear to play an important role in relapse prevention (Butler et al.,
1991). Clients need to learn that temporary lapses often occur but are not always
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detrimental. Temporary lapses can identify areas for continued learning and growth
(Gorski & Miller, 1982). Clients can be helped to develop a list of personal warning
signs (Gorski & Miller, 1982) that indicate a potential resurgence of symptoms.
This might include cognitive symptoms (e.g., worries about a particular family
member), somatic symptoms (e.g., frequent tightness in the chest), or environmental factors (e.g., physical illness of a child). When the warning signs are observed,
the client can learn to re-institute the coping skills that were developed during
therapy.
Therapist and client may identify high risk situations that have usually elicited
strong feelings of anxiety in the past. These situations can be discussed in therapy, and new coping options can be explored. After the client has had adequate
opportunity to develop and practice these new coping skills, the client should be
encouraged to seek out and confront the situations that are perceived as threatening
(Overholser, 1998). At the end of each therapy session, clients should be encouraged to negotiate the appropriate level of task so that they can leave the session
feeling certain they can confront the situation. Behavioral assignments work best
when the activity is structured to be within the abilities of the client. Effort and
learning should be praised. Excellent performance is not expected.
Although medications can reduce feelings of anxiety, their effects appear beneficial only in the short-term (Lindsay, Gamsu, McLaughlin, Hood, & Espie, 1987).
As the drug treatment continues, the beneficial effects are often reduced. Patients
who begin treatment on anti-anxiety medication show considerable reductions in
their reliance on medications after cognitive-behavioral therapy (Barlow et al.,
1992; Butler et al., 1987). Furthermore, the older medications (e.g., diazepam)
produced withdrawal symptoms and rebound increases in anxiety even when used
in recommended doses (Power, Jerrom, Simpson, & Mitchell, 1985). Some of
the newer medications (e.g., buspirone) have been found to have side-effects that
mimic anxiety symptoms, including nausea, dizziness, insomnia, and sweating
(Sramek et al., 1996).
CONCLUSIONS
A general framework for therapy can guide the cognitive-behavioral treatment
of GAD. Psychological treatments for GAD result in reductions of 50% of the
severity of somatic symptoms, 25% reductions in measures of trait anxiety and
a move from pathological to normal functioning in 50% of patients (Durham &
Allan, 1993). The beneficial effects of cognitive-behavioral therapy last longer
than other forms of psychological treatment (Durham, Allan, & Hackett, 1997)
and pharmacological treatments (Gould et al., 1997).
The treatment guidelines that have been described above were based on an
integration of prior research and clinical experience. The guidelines may provide a
useful framework for devising an integrated treatment plan that can be adapted to
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the unique needs of each client. Future research may be able to critically examine
the benefits of this approach to cognitive-behavioral therapy.
The present manuscript describes components for guiding the treatment of
GAD. These components help to structure the treatment plan while remaining
flexible to each clients unique needs. The therapist can plan to use each therapy
session to move ahead in one of these areas. However, the specific topics that are
discussed in session can be guided by the clients current needs and recent events
in the clients life. In this way, the client can feel understood while the therapist
makes progress each week in a broader treatment plan.
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