Knowledge of the efficacy of cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD) predominantly derives from randomized controlled trials (RCTs). However, there may be unique or complex issues encountered in practice, but not necessarily in the context of a controlled clinical trial. Therefore, launching a systematic dialogue between researcher and practicing clinician can be instrumental in augmenting evidence-based therapies through identification of variables that promote and interfere with clinical effectiveness. Through an initiative sponsored by the American Psychological Association’s Divisions 12 (Society for Clinical Psychology) and 29 (Psychotherapy), this study aimed to examine clinical experiences conducting CBT for GAD. The participants were 260 psychotherapists who completed an online survey on assessment and therapeutic intervention utilization and their experience of factors that limit successful GAD treatment and symptom reduction. The majority of respondents reported 20 years or less experience using ESTs for GAD, typically treating clients in outpatient clinics, treatment centers, and private practice. Some of the most commonly used interventions address clients’ maladaptive cognitions and elevated anxiety and muscle tension typical of GAD. Approximately one half of respondents reported incorporating integrative techniques into treatment. Factors perceived as limiting effective GAD treatment included severity and chronicity of GAD, presence of comorbid conditions, stressful home and work environments, client motivation and resistance to treatment, and issues encountered when executing therapy techniques. This study provides researchers with clinically derived directions for future empirical investigation into enhancing efficacy of GAD treatment.
Generalized anxiety disorder (GAD) is a chronic problem marked by pathological worry, and typically associated with a variety of physical, emotional, and cognitive symptoms, including restlessness, fatigue, irritability, muscle tension, concentration difficulty, and sleep disturbance (American Psychiatric Association, 2000). It is a highly prevalent anxiety disorder (Kessler et al., 2005), and likely to be encountered in both clinical and primary care settings. GAD is characterized by later onset than other anxiety disorders (Kessler et al.) and comprises fluctuations in symptom severity and impairment that may not be indicative of recovery (Wittchen et al., 2000 and Yonkers et al., 1996). GAD is also associated with a high degree of comorbidity that can interfere with its natural remission (e.g., Bruce et al., 2005). Finally, the disability and impairment associated with GAD is analogous to major depressive disorder and can be more extensive than pure substance use disorders, some anxiety disorders, and personality disorders, even taking into account sociodemographic variables and comorbid conditions (Grant et al., 2005).
GAD is unique in that behavioral avoidance commonly observed in other anxiety disorders is not one of its cornerstone symptoms. Rather, individuals with GAD display a tendency to perceive threat in neutral or ambiguous stimuli (Mathews & MacLeod, 1994), and engage in worry to cope with the occurrence of negative events and alterations in emotional reactivity (Newman & Llera, 2011). This process is maintained through connecting their worry with the nonoccurrence of the feared event and subsequent reduction in anxiety. Temporally linking these events then fosters positive beliefs regarding worry’s functionality, such as worry helping them to anticipate negative outcomes or worst-case scenarios or avoid shifts in negative emotions (Borkovec & Roemer, 1995; Newman & Llera). In the absence of interventions to address the aforementioned information processing biases and maladaptive cognitions, GAD has a poor prognosis captured by a low probability of symptom remission and a high likelihood of recurrence (Rodriguez et al., 2006), thereby underscoring the need for effective treatment.
