Cognitive-Behavioral Treatment of Generalized Anxiety Disorder

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

Penn State University

Reprinted from:
Newman, M. G., & Borkovec, T. D. (1995). Cognitive-behavioral treatment of generalized anxiety disorder. The Clinical Psychologist, 48(4), 5-7.


I. Description of Treatment

Cognitive behavioral therapy (CBT) of generalized anxiety disorder (GAD) is based on the theory that the disorder stems from constant perceptions of the world as a dangerous place, resulting in a process of maladaptive and habitual interactions among cognitive, behavioral, and physiological response systems. Maladaptive cognitive responses include a pre-attentive bias to threat cues (Mathews, 1990), negatively valenced images and worrisome thinking (Borkovec & Inz, 1990), and cognitive avoidance of some aspects of anxious experience (Borkovec, Shadick, & Hopkins, 1991). Maladaptive behavioral responses include subtle behavioral avoidance (Butler, Fennel, Robson, & Gelder, 1991) and slowed decision-making (Metzger et al., 1990). The physiological responses entail excessive muscle tension and an autonomic inflexibility based on a deficiency in parasympathetic tone (Thayer, Friedman, & Borkovec, 1995). The interaction of these maladaptive response systems leads to a process of spiraling intensification in anxiety. CBT attempts to replace these maladaptive reactions with multiple adaptive coping responses that target each domain of dysfunction.

Foundational to this treatment is client self-monitoring. Clients are encouraged to pay attention to any subtle shift in their anxiety level and to note interactive patterns of worrisome thinking, catastrophic imagery, physiological activity, behavioral avoidance, and the external cues that may trigger these responses. As clients become aware of their anxiety cues, they are encouraged to intervene as early as possible, using newly learned coping responses.

The early replacement of maladaptive responses with more adaptive ones creates two benefits. First, because the anxiety spiral is weaker at its initiation, coping responses have a greater chance of reducing the anxiety and of preventing its continued intensification. Second, each time the spiral occurs, its sequence of interacting responses is strengthened in memory. Therefore, early substitution of adaptive responses for maladaptive ones precludes such strengthening and instead reinforces adaptive coping sequences. As clients learn to employ adaptive responses to previously identified internal and external triggers, the triggers lose their threatening meaning and become discriminative stimuli for deployment of effective coping methods.

Adaptive coping interventions include relaxation training, self-control desensitization, and cognitive restructuring. Within these interventions, clients are taught multiple techniques. This allows the client to experiment with a variety of strategies to determine what works best for them and helps to establish flexible choices to combat previous rigid modes of responding. Relaxation techniques, including pleasant imagery, slowed paced diaphragmatic breathing, progressive muscle relaxation, differential relaxation, meditation, and cue-controlled relaxation are taught within an applied relaxation framework (Öst, 1987). Clients are also trained in Goldfried's (1971) self-control desensitization to provide frequent rehearsals of the application of relaxation skills to eliminate imagery-induced anxiety cues and worrisome thinking. Cognitive therapy techniques include identification of automatic thoughts and core beliefs, logical analysis based on probability and evidence, development of multiple alternative perspectives, behavioral testing of predictions, and decatastrophizing (Beck & Emery, 1985). Cognitive products from these interventions are then used in self-control desensitization to provide frequent practice in shifting to adaptive perspectives in response to incipient anxiety cues. Homework assignments aim at encouraging frequent applications of all of the techniques to increasingly early detections of anxious responding.


II. Summary of Studies Supporting the Treatment's Efficacy

In a meta-analysis of the extant controlled outcome studies, Borkovec 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 anxiolytic medication.

In addition to showing statistically significant improvement, CBT has also demonstrated clinically significant improvement. In 3 of the 4 interpretable studies which have assessed clinically significant change, CBT showed long-term maintenance or further gains in clinically significant change (Borkovec & Whisman, in press). However, despite demonstration of efficacy, only about half of CBT-treated clients achieve high end-state functioning. Thus, further technique development is necessary.


III. Clinical References

Craske, M.G., Barlow, D.H., & O'Leary, T. (1992). Mastery of your anxiety and worry. Albany, NY: Graywind Publications Incorporated.

Beck, A.T., & Emery, G. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books.

Goldfried, M.R. & Davison, G.C. (1969). Clinical behavior therapy. New York: Holt, Rinehart, and Winston Inc.

Smith, J.C. (1985). Relaxation dynamics: Nine world approaches to self-relaxation. Champagne, IL: Research Press.


IV. Resources for Training

There are future plans to establish training in cognitive behavioral therapy of GAD at

Graywind Publications at Executive Park Drive
Albany, NY 12203
(518) 438-3231


V. References

Borkovec, T.D., & Inz, J. (1990). The nature of worry in generalized anxiety disorder: A predominance of thought activity. Behaviour Research and Therapy, 28, 153-158.

Borkovec, 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, DC: 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 (Eds.), Chronic anxiety, generalized anxiety disorder, and mixed anxiety depression (pp. 29-51). New York: Guilford Press.

Butler, G., Fennel, M., Robson, P., & Gelder, M. (1991). Comparison of behavior therapy and cognitive behavior therapy in the treatment of generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 59, 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 generalized anxiety disorder. British Journal of Psychiatry, 165, 315-323.

Goldfried, M.R. (1971). Systematic desensitization as training in self-control. Journal of Consulting and Clinical Psychology, 37, 228-234.

Mathews, A. (1990). Why worry? The cognitive function of anxiety. Behaviour Research and Therapy, 28, 455-468.

Metzger, R. L., Miller, M., Cohen, M., Sofka, M., & Borkovec, T. D. (1990). Worry changes in decision-making: The effect of negative thoughts on cognitive processing. Journal of Clinical Psychology, 46, 78-88.

Öst, L. (1987). Applied relaxation: Description of coping technique and review of controlled studies. Behaviour Research and Therapy, 25, 397-409.

Thayer, J.F., Friedman, B.H., & Borkovec, T.D. (1996). Autonomic characteristics of generalized anxiety disorder and worry. Biological Psychiatry, 39, 255-266.


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