Generalized Anxiety Disorder and Worrying A Comprehensive Handbook for Clinicians and Researchers

A comprehensive and authoritative guide to anxiety disorder and worry

Generalized Anxiety Disorder offers a comprehensive review of the most current research and therapeutic modalities related to generalized anxiety disorder and worry (GAD). With contributions from an international panel of experts, the Handbooklinks the basic science of anxiety and worry to the effective treatments that can be applied to help those who suffer from these conditions.

Reflecting the most recent research and developments on the topic, theHandbook contains information on cross-cultural issues, transdiagnostic questions, as well as material on learning theory, biological theory, psychotherapy, and psychopharmacology. The contributors offer an in-depth examination of a range of topics such as rumination and obsessions and contains several novel approaches to treating the disorder. This comprehensive resource:

• Contains the most current information available on the topic
• Explores the consequences of worrying and other mental disorders such as illness anxiety and sleep disorders
• Includes contributions from an international panel of experts
• Offers insight into the future of treatment outcomes and translational research

Written for practitioners, researchers, and trainees of clinical psychology and psychiatry, Generalized Anxiety Disorder addresses the assessment and empirically supported treatment of generalized anxiety disorder.

ALEXANDER L. GERLACH is Professor of Clinical Psychology and Psychotherapy at the University of Cologne, where he is Director of the outpatient cognitive behavioral psychotherapy treatment center.

ANDREW T. GLOSTER is Professor of Psychology at the University of Basel, where he heads the Division of Clinical Psychology and Intervention Science.

1 Worry, GAD, & their importance

1.1 What is Worry – What is GAD? Epidemiology

1.2 Where do GAD patients present and what cost for the health system?

1.3 Introduction and Overview of the Handbook

2 Assessing Worry: An Overview

2.1 Introduction

2.2 What is worrying?

2.3 Assessments of GAD and worry

2.3.1 Challenges in assessing GAD and worry

2.3.2 Assessing worry and GAD with the event sampling methodology

2.4 Differential diagnosis of GAD and the overlap of worry with related constructs

2.5 Conclusion

3 Perceptions of Threat

3.1 Introduction

3.2 Measuring perceptions of threat

3.3 Research linking perceptions of threat and worrying

3.4 Formation of threat perception: potential antecedents

3.4.1 Negative beliefs.

3.4.2 Intolerance of uncertainty.

3.4.3 High performance standards.

3.4.4 Goal investment

3.5 Moderators of the relationship between perceived threat and worry

3.6 Potential Clinical Implications

3.7 Future Directions for Research

3.8 Conclusions

4 Transdiagnostic View on Worrying and Other Negative Mental Content

4.1 Introduction

4.2 Is Worry a Transdiagnostic Process?

4.3 Is Worry Just a Variant of Transdiagnostic RNT?

4.3.1 Definition of Repetitive Negative Thinking (RNT)

4.3.2 Evidence for the Construct of RNT

4.3.3 Looking Beyond Worry and Rumination

4.3.4 Assessment of RNT from a Transdiagnostic Perspective

4.3.5 Conclusions

4.4 Theoretical Models of RNT as a Transdiagnostic Process

4.4.1 Emotional Avoidance Models

4.4.2 Emotion Dysregulation Models

4.4.3 Meta-Cognitive Model

4.4.4 Information Processing and Cognitive Control Models

4.4.5 An Integrative Model of Transdiagnostic RNT

4.4.5.1 RNT as an Adaptive Process

4.4.5.2 RNT as a Maladaptive Process

4.4.6 Conclusions

4.5 Treatment of Worry/RNT from a Transdiagnostic Perspective

4.5.1 Which Interventions are Efficacious to Reduce RNT?

4.5.2 Where to Go From Here?

4.6 Conclusions and Future Direction

5 Worry and other mental health problems

5.1 Introduction

5.2 Health anxiety

5.2.1 Health anxiety: Definition, diagnosis, and prevalence

5.2.2 Assessment

5.2.2.1 Research findings on worry in health anxiety: Cross-sectional findings

5.2.2.2 Research findings on worry in health anxiety: Longitudinal findings

5.2.2.3 Research findings on worry in health anxiety: Findings from treatment studies

5.2.3 Worry and health anxiety: Concluding remarks

5.3 Worry and insomnia disorder

5.3.1 Insomnia disorder: Definition, diagnosis, and prevalence

5.3.2 Assessment

5.3.2.1 Research findings on worry in insomnia disorder: Cross-sectional findings

5.3.2.2 Research findings on worry in insomnia disorder: Longitudinal findings

5.3.2.3 Research findings on worry in insomnia disorder: Findings from treatment studies

5.3.3 Worry and insomnia disorder: Concluding remarks

5.4 Concluding Remarks and Future Directions

6 Learning Science and Generalized Anxiety Disorder (GAD)

6.1 Introduction

6.2 Basic conditioning theory and avoidance learning

6.3 Excitatory fear mechanisms and fear generalization in GAD

6.4 Borkovec’s Avoidance Model

6.5 Relational Frame Theory and GAD

6.6 AARR and Generalized Anxiety Disorder

6.7 Conclusion

7 Cognitive Behavioural Models of Generalized Anxiety Disorder: Toward a Synthesis

7.1 Introduction

7.2 Historical Underpinnings of Cognitive-Behavioural Conceptualizations of GAD

7.3 Distal Theories of GAD

7.3.1 The Cognitive Avoidance Model

7.3.2 Metacognitive Theory

7.3.3 Intolerance of Uncertainty Model

7.3.4 Acceptance-Based Model

7.3.5 Emotion Dysregulation Model

7.3.6 Contrast Avoidance Model

7.4 Proximal Theories Explaining the Process of Worrying

7.4.1 Mood As Input Hypothesis

7.4.2 The Cognitive Model of Pathological Worry

7.5 Cognitive-Behavioural Models of GAD: Synthesis and Discussion

7.5.1 Distal Theories

7.5.2 Proximal Theories

7.6 Conclusion

8 Structural and functional neuroanatomy of generalized anxiety disorder

8.1 Introduction

8.2 Brain functions related to fear and anxiety

8.3 Brain structure and function in GAD

8.3.1 Assessment of brain structure and function

8.3.1.1 Assessment of brain structure

8.3.1.2 Assessment of brain function

8.3.2 Brain structure in GAD

8.3.2.1 Children/adolescents

8.3.2.2 Adults

8.3.2.3 White matter volume and structural connectivity

8.3.3 Brain function in GAD

8.3.3.1 Children and adolescents

8.3.3.2 Adults

8.3.3.3 Functional connectivity

8.3.3.4 Treatment studies

8.4 Integration of findings and outlook

9 Cultural Perspectives in Understanding, Treating, and Studying Worry and Generalized Anxiety Disorder

9.1 Introduction

9.2 Culture and Psychopathology

9.3 Cultural Conceptualizations of GAD

9.3.1 The Unidimensional Model of a Cultural Conceptualization of GAD

9.3.2 The Bidimensional Model of Cultural Conceptualization of GAD

9.4 Cultural Influences on Worry and GAD

9.4.1 Racial and Ethnic Differences

9.4.1.1 Prevalence of GAD

9.4.1.2 Contents and structure of worry.

9.4.1.3 Manifestation of worry.

9.4.2 Social and Contextual Factors, Gender, and Age

9.4.3 Acculturation and GAD

9.5 General Considerations on Becoming Culturally Competent Therapists

9.5.1 A tripartite Model of Multicultural Competence

9.5.1.1 Culturally Sensitive Attitudes and Beliefs

9.5.1.2 Cultural Knowledge

9.5.1.3 Culturally Competent Skills

9.5.2 Cultural Formulation Interview: Diagnosing GAD from a Cultural Perspective

9.5.2.1 Cultural definition of the problem.

9.5.2.2 Cultural perceptions of cause, context, and support

9.5.2.3 Cultural factors affecting coping and help-seeking.

9.5.3 Cultural Considerations in Diagnosing GAD

9.5.3.1 Category Fallacy

9.5.3.2 A Cultural Dissection of DSM-5 GAD Criteria

9.5.3.3 Other Diagnostic Instruments of GAD

9.5.4 Culturally Adapted Treatments of GAD

9.5.4.1 Culture Adapted Psychopharmacological Treatment.

9.5.4.2 Culturally Adapted Cognitive-Behavioral Therapies

9.5.4.3 Culture-Specific Resources and Healing Practices as Adjunct Treatments

9.6 Considerations and Directions for Research on Culture and GAD

9.6.1 Establish Measurement Equivalence

9.6.2 Increase Use of Longitudinal Data and Structure-Oriented Comparisons

9.7 Conclusion

10 Cognitive Behavioral Therapy (CBT) for Generalized Anxiety Disorder (GAD)

10.1 Introduction

10.2 Implementation of CBT for GAD

10.2.1 Self-Monitoring.

10.2.2 Relaxation Training.

10.2.3 Progressive Muscle Relaxation (PMR).

10.2.4 Imagery Training.

10.2.5 Meditation.

10.2.6 Applied Relaxation.

10.2.7 Self-Control Desensitization (SCD).

10.2.8 Stimulus Control.

10.2.9 Worry exposure.

10.2.10 Cognitive Restructuring

10.3 Systematic treatment conceptualizations for GAD

10.3.1 Metacognitive therapy.

10.3.2 Intolerance-of-uncertainty therapy.

10.3.3 Emotion-regulation therapy.

10.3.4 Predictors of Treatment Outcome of CBT for GAD

10.4 Psychotherapy for GAD: Variations and communalities

11 Interpersonal and Emotion-focused Therapy (I/EP) for Generalized Anxiety Disorder

11.1 Introduction

11.2 Overview, Process, and Implementation of Interpersonal Therapy/ Emotional Therapy

11.2.1 Processing Therapy (I/EP).

11.2.2 Social skills training.

11.2.3 Use of therapist-client interaction as treatment tool.

11.2.4 Emotional Processing aspects of I/EP.

11.3 Future Directions of I/EP

12 Acceptance-based behavioral therapies for GAD

12.1 Introduction

12.2 An acceptance-based behavioral model of GAD

12.2.1 Problematic relationship to internal experiences

12.2.2 Rigid experiential avoidance

12.2.3 Restrictions (behaviorally and/or attentionally) in engaging in meaningful actions

12.3 Acceptance-based Behavioral Therapy for GAD

12.3.1 Assessment of ABBT components

12.3.2 Development of the therapeutic relationship

12.3.3 Psychoeducation to cultivate awareness/acceptance

12.3.3.1 An acceptance-based behavioral model of fear and anxiety

12.3.3.2 Understanding worry.

12.3.3.3 Clear and muddy emotions.

12.3.3.4 Paradoxical effects of control.

12.3.4 Developing habits of awareness/acceptance

12.3.4.1 Monitoring/noticing early cues.

12.3.4.2 Formal mindfulness practices

12.3.4.3 Informal mindfulness.

12.3.5 Clarifying what matters

12.3.5.1 Goal/rigidly defined by one behavior.

12.3.5.2 Desire to control the uncontrollable.

12.3.5.3 Desire to be perfect.

12.3.6 Putting it all together – doing what matters

12.3.6.1 Clarifying emotions.

12.3.6.2 Choosing actions

12.3.6.3 Addressing barriers

12.3.7 Efficacy and effectiveness of ABBT approaches

12.4 Future directions

13 Short-term psychodynamic therapy of generalized anxiety disorder

13.1 Introduction

13.2 A psychodynamic model of GAD

13.3 Short-term psychodynamic therapy for GAD

13.3.1 Module 1: Informing the patient about GAD and its treatment: the socialization interview

13.3.2 Module 2: Motivating, addressing ambivalence and setting treatment goals

13.3.3 Module 3: Supportive Interventions and establishing a secure therapeutic alliance

13.3.4 Module 4: Identifying and focusing on the CCRT underlying the GAD symptoms

13.3.4.1 Module 4.1: Focusing on the warded-off affect – experiencing the wish component (W) of the CCRT

13.3.4.2 Module 4.2: The RO component of the CCRT – modifying underlying internalized object relations

13.3.4.3 Module 4.3: Changing the RS component: encouraging the patient to confront the feared situation and to give up avoidance

13.3.4.4 Module 4.4: Fostering more adaptive internal responses of the self (RS): the internalized encouraging dialogue

13.3.5 Module 5: Addressing (potential) non-response and resistance

13.3.6 Module 6: Termination and Relapse Prevention

13.3.7 Phases of treatment

13.4 Phases of treatment

13.4.1 Diagnostic assessments, informing the patient and making treatment arrangements (introductory sessions)

13.4.2 Early phase

13.4.3 Middle phase

13.4.4. Termination phase (treatment sessions 17-22)

13.4.5 Booster sessions

13.5 Discussion

14 Pharmacological treatment of generalized anxiety disorder

14.1 Introduction

14.2 Initial treatment

14.3 Continuation treatment

14.4 The contentious place of benzodiazepines

14.5 The place of pregabalin

14.6 Tolerability concerns

14.7 Further management after non-response to initial treatment approaches

14.8 Stopping treatment

14.9 Potential novel targets for pharmacological treatment

14.10 Conclusions

15 Internet- and computer-based treatments of GAD

15.1 Introduction

15.2 Internet-supported psychological treatment

15.2.1 Effects of internet-supported psychological treatments for GAD

15.3 Cognitive Bias Modification

15.3.1 Effects of CBM for GAD

15.4 Discussion and future directions

16 GAD in children and adolescents

16.1. Introduction

16.2. Classification

16.3. Assessment

16.4. Treatment

16.4.1 The evidence base for the treatment of (any) childhood anxiety disorders

16.4.2 The evidence base for the treatment of childhood GAD

16.5. Psychotherapy for childhood GAD

16.6. Case example of a treatment based on the Laval model of GAD

16.6.1 Treatment components

16.6.2 Developmental considerations

16.7. The case of Sara

16.7.1 Assessment

16.7.2 Course of treatment

16.7.3 Worry awareness training and socialization to the treatment model

16.7.4 Problems versus worries

16.7.5 Targeting intolerance of uncertainty

16.7.6 Worry behaviors

16.7.7 Identifying Sara’s treatment goals

16.7.8 Behavioral experiments

16.7.9 Problem solving

16.7.10 Cognitive avoidance and imaginal exposure

16.7.11 Termination and relapse prevention

16.8. Additional exercises for children with GAD

16.9. Summary

17 The road ahead: what research paths should be taken in order to improve future treatments?

17.1. Nosological Considerations: Diagnostic Overlap?

17.2. GAD in the days of R-DoC and Network Analysis

17.3. What can diagnostic-specific information add?

17.4. What context variables impact treatment?

17.5. The path forward

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