Magazine article Clinical Psychiatry News

Tweaking CBT Can Boost Outcomes in Treatment of GAD

Magazine article Clinical Psychiatry News

Tweaking CBT Can Boost Outcomes in Treatment of GAD

Article excerpt

SAN FRANCISCO -- The search is on for ways to refine cognitive-behavioral therapy for generalized anxiety disorder in order to improve upon current relatively modest success rates.

Cognitive-behavioral therapy (CBT) is less effective for generalized anxiety disorder (GAD) than for the other anxiety disorders. Only about one-half of patients are improved post treatment, and less than one-third reach recovery, noted Richard E. Zinbarg, PhD, at the annual conference of the Anxiety and Depression Association of America.

"We clearly have lots of room for improvement," observed Dr. Zinbarg, professor of psychology at Northwestern University in Evanston, 111.

At a session on advances in treatment of GAD, investigators presented randomized clinical trials assessing a variety of specific strategies aimed at enhancing the effectiveness of CBT in evidence-based fashion. The trials included a study of the impact of having patients keep a worry outcome journal, an exploration of the potential deleterious effects of a phenomenon known as relaxation-induced anxiety, and a study of the effectiveness of emotion regulation therapy, a relatively recent form of psychotherapy that's part of the so-called "third wave" of CBT.

Worry outcome journal

Lucas LaFreniere observed that, while CBT has been broadly shown to be effective for GAD, the various forms of CBT are packages of components that often include psychoeducation, stimulus control, behavioral experiments, exposure, cognitive reframing, relaxation training, and other elements in various combinations and sequences. Almost none of these specific components has been evaluated formally to learn whether they are pulling their weight therapeutically and making a positive contribution to outcomes.

Mr. LaFreniere, a doctoral student in clinical psychology at Pennsylvania State University in Hershey, presented a randomized trial of one such component, worry outcome monitoring, which currently is incorporated in some but not all CBT programs for GAD. Mr. LaFreniere and his coinvestigators developed a version of worry outcome monitoring they dubbed the worry outcome journal, or WOJ, which he characterized as "a brief ecological momentary intervention for worry."

The WOJ uses cell phone technology to create a therapist-independent treatment for reducing worry. Based upon the positive study findings, worry outcome monitoring now can legitimately be considered an evidence-based intervention that deserves to be incorporated as a routine component of CBT for GAD, he said.

The WOJ works like this: At four random times per day, WOJ users receive a phone message to drop what they're doing and record on a chart what they're currently worrying about. They briefly note the date and time, the content of their worry the distress it's causing on a 1-7 scale, how much time they're spending thinking about it, and their prediction as to the likelihood that this negative event actually will come to pass, which by the nature of their illness generally is unrealistically sky high early on in treatment. Later, they return to record whether the worrisome outcome occurred. The WOJ data are often reviewed in session.

The hypothesis was that the WOJ would reduce worry by aiding GAD patients in attending to their worries more thoroughly and objectively, recognizing in the moment the high cost of their worrying in terms of distress and cognitive interference, forming more realistic predictions about the future, and changing their conviction that excessive worrying is a worthwhile use of their time.

"One thing that particularly motivates me as a treatment researcher is the idea that those with GAD could be making themselves chronically miserable in an effort to protect themselves from future catastrophes that likely are not even going to happen. That's a lot of human suffering that isn't necessary. What we can do to help with that, we should do," Mr. …

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