Generalized Anxiety Disorder

Resources:
Rygh, J. L., & Sanderson, W. C. (2004). Treating Generalized Anxiety Disorder: Evidence-based strategies, tools, and techniques. The Guildford Press.
Anxiety Disorder Interview Schedule Adult Version (ADIV-IV) Website:     https://global.oup.com/academic/product/anxiety-disorders-interview-schedule-adis-iv-parent-interview-schedules-9780195183863?cc=us&lang=en&
Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) Website: http://www.scid4.org/index.html

Client Self-Report Measures
Three longstanding, widely utilized, empirically validated and reliable evidence-based client self-report instruments with good psychometric properties can be used for relatively quick and efficient initial screening or assessment of GAD and associated anxiety and worry: The Beck Anxiety Inventory (BAI; Beck, et al., 1988; Beck & Steer, 1990) is a short self-report measure of the primary psychological and somatic symptoms of general anxiety, and is helpful since “general anxious arousal is an essential feature of GAD” (Rygh & Sanderson, 2004a; p. 36). The Penn State Worry Questionnaire (PSWQ; Meyer, et al., 1990) is a brief measure of worry and is helpful for distinguishing clients with GAD from clients with other anxiety disorders. The Generalized Anxiety Disorder Questionnaire – IV (GADQ-IV; Newman, et al., 2002) is another self-report measure and is helpful because it is designed around GAD diagnostic criteria.

In addition, designed specifically for use with children, the Screen for Child Anxiety Related Emotional Disorders (SCARED; Berhamer, et al., 1999) is an empirically validated and reliable evidence-based client self-report instrument demonstrating good psychometric properties across various cultures (Essau, et al., 2002;Su et al., 2008; Essau, et al., 2013).

Beck Anxiety Inventory (BAI) Website:
http://www.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail htm?Pid=015-8018-400
Measurement Instrument Database for the Social Sciences: Penn State Worry Questionnaire:
http://www.midss.org/content/penn-state-worry-questionnaire-pswq
Generalized Anxiety Disorder Questionnaire-IV (GADQ-IV) Psychometric Investigation:
http://dx.doi.org/10.1016/S0005-7894(02)80026-0

Resources The California Evidence-Based Clearinghouse for Child Welfare: Screen for Child Anxiety Related Emotional Disorders (SCARED): http://www.cebc4cw.org/assessment-tool/screen-for-childhood-anxiety-related-emotional-disorders-scared/

Intervention Strategies

Cognitive Behavioral Therapies (CBT)
Today there is a substantial literature based on clinical evidence, including a substantial accumulation of studies employing randomized controlled treatment designs, which supports the effectiveness of cognitive-behavioral therapies (CBT) (including various techniques which fall under the CBT umbrella) with GAD. “CBT … is the only form of psychological treatment for GAD that has been repeatedly subjected to rigorous, well-controlled treatment outcome research (Rygh & Sanderson, 2004; p. 8). Still, it should be noted that even for evidence-based treatments, there are differences in symptom improvement outcomes among different clinicians (Baldwin, et al., 2007; Lutz, et al., 2007) and with GAD, the counselor’s CBT competence was found to be a limiting factor in client outcomes (Westra, et al., 2011); therefore, CBT approaches for GAD may be more effective when they fall within the counseling professional’s practice competencies.

CBT approaches to GAD are based on the assumption that negative beliefs play an important role in the development of excessive worry; correspondingly, the treatment targets negative beliefs about uncertainty, and worries (Dugas & Robichaud, 2007). For instance, evidence suggests clients with GAD tend to experience more verbal thoughts than images, which may be problematic (Hirsch, et al., 2012), embrace the negative belief that their worries are uncontrollable and threatening (Penney, Mazmanian, & Rudanycz, 2011), and consequently have somatic anxiety for which worry and negative affect are main contributors (Donegan & Dugas, 2012; Llera & Newman, 2010).

Early treatment studies and meta-analytic studies comparing cognitive therapies with other psychosocial approaches (such as analytic and psychodynamic psychotherapies, behavior therapy and anxiety management  training, and, cognitive therapy concluded that, generally speaking, CBT provided the most improvement  (Borkovec and Ruscio, 2001; Chambless & Ollendick, 2001). Subsequently, the efficacy of CBT seems to have been well-established (Stewart & Chambless, 2008). CBT approaches have been associated with such intermediate and long-term outcomes as: enhancing access to benign meanings in place of worrisome intrusive thoughts (Hirsch & Hayes, 2009), decreased threatening interpretations of the intrapersonal and interpersonal worlds (Amir & Taylor, 2012; Reinecke, et al., 2013), increases in self- efficacy and reduction of social anxiety (Goldin, et al., 2012), and reduction of worry and consequential somatic anxiety symptoms (Donegan & Dugas, 2012). Further, at least one study reported positive outcomes developmentally modified CBT in the treatment of 4 – 7 year old child clients with anxiety disorders (Hirschfeld-Becker, et al., 2010); and family CBT has been reported to be effective with clients aged 7 – 14 years old (Kendall, et al., 2008).

In practice, the CBT approach targets modifications in the client’s cognitive distortions, anxious affect, behavioral components of GAD, and to restructure client assumptions (Beck, Emery, & Greenberg, 2005). CBT for GAD sets intermediate outcome goals and utilizes intermediate interventions to: socialize the client for counseling; treat the cognitive component using restructuring, positive imagery, worry exposure, improving problem orientation, setting worry-free zones and other tactics; treating the physiological component with relaxation and sensitization; and treat the behavioral component with response prevention, practice and in vivo exposure, and planning (Rygh & Sanderson, 2004). Well- established resources are listed below.

Resources:
Beck, A. T., Emery, G., & Greenberg, R. (2005). Anxiety disorders and phobias: A cognitive perspective (Revised edition). Cambridge, MA: Basic Books.

Kendall, P. C., Gosch, E., Hudson, J. L., & Flannery-Schroeder, E. (2008). Cognitive-behavioral therapy for anxiety disordered youth: A randomized clinical trial evaluating child and family modalities. Journal of Consulting and Clinical Psychology, 76, 282-207. doi: 10.1037/0022-006X.76.2.282.

Rygh, J. L., & Sanderson, W. C. (2004a). Treating Generalized Anxiety Disorder: Evidence-based strategies, tools, and techniques. The Guildford Press.

Rygh, J. L., & Sanderson, W. C. (2004b). Treating Generalized Anxiety Disorder. NY: The Guildford Press. 

Reprint: Newman, M. G., & Borkovec, T. D. (1995). Cognitive-behavioral treatment of generalized anxiety disorder. The Clinical Psychologist, 48(4), 5-7: http://www.div12.org/psychological-treatments/treatments/cognitive-and-behavioral-therapies-for-generalized-anxiety-disorder/

Psychiatry Online: CBT for GAD with Integrations from Interpersonal and Experiential Therapies: http://focus.psychiatryonline.org/article.aspx?articleid=49792

Supplemental and Integrative Approaches
Although CBT for GAD has been shown to be efficacious and has been reported to produce significant improvement, CBT is not beneficial for all clients and does not always facilitate the client’s return to high endstate functioning (Newman, et al., 2008; Waters & Creaske, 2005). In response, integrative psychotherapeutic approaches sometimes are used and some have been subject of clinical research (Heimberg, Turk, & Mennin, 2004; Roemer, Orsillo, & Salters-Pedneault, 2008).

Integrating Mindfulness-based or Self-awareness-based Approaches.
Some authors and researchers recommend integrating mindfulness-based or self-awareness-based approaches into GAD counseling. For example, Connolly Gibbons, et al. (2008) conducted a large client database analysis and concluded that across counseling approaches, interventions which focus on improvements in self-understanding, compensatory skills, and improved views of self, all were associated with positive symptom change. Generally speaking, these approaches attempt to facilitate within the client a “an open attention to one’s present experience, accompanied by a nonjudgmental, accepting attitude toward whatever one encounters”, including internal and external experiences (Brown, Marquis, & Guiffrida, 2013; p. 96). Hofman et al. (2010). conducted a meta-analytic review of mindfulness-based therapy with anxiety and depression, found relatively robust effect sizes for improvement in anxiety and depression symptoms, and concluded that these counseling approaches were “moderately effective for improving anxiety” (p. 169). In a somewhat similar vein, Roemer & Orsillo (2008) evaluated the effects of an acceptance-based behavior therapy for GAD which targeted clients’ “experiential avoidance”, that is, their “attempts to alter the intensity or frequency of unwanted internal experiences”, by “using strategies aimed at increasing awareness and intended action in important life domains” (Roemer, Orsillo, & Salters-Pedneault, 2008). They reported the treatment resulted in decreased experiential avoidance and increases in mindfulness – and statistically significant reductions in GAD and mood symptoms in a large percentage of the clients studied (Roemer, Orsillo, & Salters-Pedneault, 2008).

Resources:
Brown, A. P., Marquis, A., & Guiffrida, D. A. (2013). Mindfulness-based interventions in counseling. Journal of Counseling & Development, 91, 96-104.

Hoffman, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78, 169-183. doi: 10.1037/a0018555.

Roemer, L., Orsillo, S. M., & Salters-Pedneault, K. (2008). Efficacy of an acceptance-based behavior therapy for Generalized Anxiety Disorder: Evaluation in a random controlled trial. Journal of Consulting and Clinical Psychology, 76, 1083-1089. doi: 10.1037/a0012720.

Integrating Interpersonal Approaches.
Since interpersonal problems play a role in maintaining GAD symptomotology, some other authors and researchers recommend integrating interpersonal therapy approaches into GAD counseling (Borkovec, et al, 2004; Crits-Christoph, 2002; Eng & Heimberg, 2006; Salzer et al, 2011). For example, Salzer, et al. (2011) conducted a pilot clinical study which led to the conclusion that interpersonal subtype may be a complex factor among GAD clients and may be associated with counseling outcomes. Generally speaking, these approaches attempt to reduce the maintenance of GAD symptoms by the client’s “emotional processing avoidance” and “interpersonal problems” (Newman, et al., 2011; p. 171). Newman and colleagues (2008) reported evidence suggesting integrative approaches employing interpersonal therapy components leads to significant decreases in GAD symptoms.

Resources:
Newman, M. G., Castonguay,  L. G., Borkovec, T. D., Fisher, A. J., & Nordberg, S. S. (2008). An open trial of integrative therapy for Generalized Anxiety Disorder. Psychotherapy: Theory, Research, Practice, Training, 45, 135-147. doi: 10.1037/0033-3204.45.2.135.

Salzer, S., Pincus, A. L., Hoyer, J., Kreische, R., & Leibing, E. (2008). Interpersonal subtypes within Generalized Anxiety Disorder. Journal of Nervous and Mental Disease, 185, 314-319. doi: 10.1037/a0022013.

Supplemental and Integrative Approaches: Informed Practice.
Although there is growing evidence for GAD counseling that integrates mindfulness and self-awareness approaches, interpersonal methods, and other strategies, to date there is a smaller body of clinical evidence for these than for CBT. In fact, in one recent randomized controlled trial with an integration of CBT with emotion-focused and interpersonal counseling, Newman et al. (2011) reported that “interpersonal and emotional techniques may not augment CBT” equally well for all GAD clients (p. 171). Therefore, counselors must make their own informed decisions about these practices. Informative resources include:

Heimberg, R. G., Turk, C. L., & Mennin, D. S. (2004). Generalized anxiety disorder: Advances in research and practice. NY: Guilford Press.

Jongsman, A. E., Jr. (Ed.). (2004). The complete anxiety treatment and homework planner. Hoboken, NJ: Wiley.

Portman, M. E. (2009). Generalized anxiety disorders across the lifespan: An integrative approach. NY: Springer.

Rygh, J. L., & Sanderson, W. C. (2004a). Treating Generalized Anxiety Disorder: Evidence-based strategies, tools, and techniques. The Guildford Press.

Psychopharmacology
Psychopharmological intervention also may a part of treatment for GAD, usually with psychoactive medication being prescribed alongside psychological counseling (Rygh & Sanderson, 2004; Sussman & Stein, 2001). ). Treatment with medication usually should be an adjunct to counseling intervention, with exclusive psychopharmacological  treatment of GAD being reserved for client situations that prove to be “highly refractory psychological interventions” (Rygh & Sanderson, 2004; p. 7). As a rule of thumb, treatment with medication is most indicated in situations where: counseling intervention has already been tested but has produced insufficient improvement ; the client’s daily functioning is significantly impaired by GAD, or the client’s anxiety level is intolerable; or waiting out a trial of psychological counseling would create extreme difficulties for the client (Rygh & Sanderson, 2004 In situations where psychopharmacology is part of GAD treatment, the counseling professional has responsibilities for assisting the client to: cooperate with referrals, evaluations, and testing; understand the treatment options, including expected results and possible side effects of medication; take medications as prescribed and adhere to the medication regimen; report of medication effectiveness and side effects; attend and cooperate during counseling sessions as well as appointments with the physician; and work towards a treatment goal of reduction of symptoms or remission without or with a minimum amount of medication (Purselle, Nemeroff, & Jongsma, 2003).

Common medication approaches to the treatment of GAD include the following: Buspirone is a medication of choice for GAD. Unlike other benzodiazepines, Buspirone is slow-acting, requiring 2 – 6 weeks to produce symptom change; therefore, clients may tend to discontinue use prematurely and so the counselor can assist successful Buspirone treatment by educating and supporting the client in their adherence to the regimen. Also, although Buspirone reduced GAD symptoms, it does not usually decrease panic attacks if they are present. Clients much take this medication on an ongoing basis, not just when anxiety symptoms worsen. If anxiety symptoms are severe, other Benzodiazepines (such as Ativan, Valium, Xanax) commonly are used to provide immediate anxiety symptom relief; however, Benzodiazepines may produce problems with tolerance and dependence when used long-term, and they are inadvisable when the client has a history of alcohol or other substance abuse. SSRIs or venlafaxine also sometimes are prescribed for GAD when Buspirone does not produce intended outcomes (Dziegielewski, 2006; Preston & Preston, 2004; Rygh & Sanderson, 2004).

Resources:
Dziegielewski, S. F. (2006). Psychopharmacology handbook for the non-medically trained. NY: Norton. Preston, J., & Preston, J. (2004). Clinical psychopharmacology made ridiculously simple: Edition 5. Miami, FL: Medmaster.

Brown, A. P., Marquis, A., & Guiffrida, D. A. (2013). Mindfulness-based interventions in counseling. Journal of Counseling & Development, 91, 96-104.

Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and  evidence. Annual Review of Psychology, 52, 685-716.

Connolly Gibbons, M. B., Crits-Christoph, P., Barber, J. P., Wiltsey Stirman, S., Gallop, R., Goldstein, L. A., Termes, C. M., & Ring-Kurtz, S. (2008). Unique and common mechanisms of change across cognitive and dynamic psychotherapies. Journal of Consulting and Clinical Psychology, 77, 801-813.

Crits-Christoph, P. (2002). Psychodynamic interpersonal treatment of generalized anxiety disorder. Clinical Psychology: Science and Practise, 9, 81-84.

Deffenbacher,  J. L. (1992) A little more about behavioral assessment. Journal of Counseling & Development, 70, 632-634.

Donegan, E., & Dugas, M. J. (2012). Generalized Anxiety Disorder: A comparison of symptom change in adults receiving cognitive-behavioral therapy or applied relaxation. Journal of Consulting and Clinical Psychology, 80, 490-496.

Dugas, M. J., & Robichaud, M. (2007). Cognitive-behavioral treatment for generalized anxiety disorder: From science to practice. NY: Routledge.

Eng, W., & Heimberg, R. G. (2006). Interpersonal correlates of generalized anxiety disorder. Self versus other perception. Journal of Anxiety Disorders, 20, 380-387.

Essau, C. A., Muris, P., & Ederer, E. M. (2002). Reliabilty and validity of the “Spencer Children’s Anxiety Scale” and the “Screen for Child Anxiety Related Emotional Disorders” in German children. Journal of Behavior Therapy and Experimental Psychiatry, 33, 1-18.

Essau, C. A., Anastassiou-Hadjicharalambous, X., & Munoz, L. (2012). Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED) in Cypriot children and adolescents. European Journal of Psychological Assessment, 29, 19-27.

First, M. B., Spitzer, R. L., Gibbon, M., & Williams,  J. B. (1997). Structured Clinical Interview for DSM-IV Axis I Disorders, Clinical Version (SCID-CV). Washington, DC: American Psychiatric Association.

Goldin, P. R., Ziv, M., Jazaieri, H., Werner, K., Heimberg, R. G., Kraemer, J., & Gross, J. J. (2012). Cognitive reappraisal self-efficacy mediates the effects of individual cognitive-behavioral therapy for social anxiety disorder. Journal of Consulting and Clinical Psychology, 80, 1034-1040.

Grant, B. F., Hasin, D. S., Stinson, F. S., Dawson, D. A., Ruan, W. J., Goldstein, R. B., … Huang, B. (2005). Prevalence, correlates, comorbidity, and comparative disability of DSM-IV generalized anxiety disorder in the USA: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Psychological Medicine, 35, 1747-1759. doi: 10.1017/S0033291705006069.

Hirsch, C. R., & Hayes, S. (2009). Looking on the bright side: Accessing benign meaning reduces worry. Journal of Abnormal  Psychology, 118, 44-54.

Hirsch, C. R., Mathews, A., Hayes, S., Perman, G., & Borkovec, T. (2012). The extent and nature of imagery during worry and positive thinking in Generalized Anxiety Disorder. Journal of Abnormal  Psychology, 121, 218-243.

Hirschfield-Becker, D. R., Masek, B., Henin, A., Pollock-Wurman, R. A., Ollendick, T. H., Blakely, L. R., McQuade, J., DePetrillo,  L., Briesch, J., Rosenbaum, J. F., & Biederman, J. (2010). Cognitive behavior therapy for 4- to 7-year children with anxiety disorders: A randomized clinical trial. Journal of Clinical and Consulting Psychology, 78,498-510.

Hoffman, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78, 169-183. doi: 10.1037/a0018555.

Kendall, P. C., Gosch, E., Hudson, J. L., & Flannery-Schroeder, E. (2008). Cognitive-behavioral therapy for anxiety disordered youth: A randomized clinical trial evaluating child and family modalities. Journal of Consulting and Clinical Psychology, 76, 282-207. doi: 10.1037/0022-006X.76.2.282.