As discussed in previous chapters in this volume, generalized anxiety disorder (GAD) is a relatively common disorder that is associated with significant distress and functional impairment. Fortunately, advances in both pharmacotherapy and psychotherapy have resulted in a greater likelihood of providing effective treatment. Unfortunately, many more inroads remain to be made to clarify what works for whom and how. In this chapter, we concentrate on what we do and do not know about psychosocial treatments for generalized anxiety disorder. First, we describe the psychological aspects of generalized anxiety disorder that appear to be involved in the maintenance of the disorder and, thus, must be addressed in treatment. Then, we review the outcome literature relevant to generalized anxiety disorder. Finally, we discuss empirically supported psychological treatment strategies and suggest potential directions for future clinical research.
Future Directions of Therapy for Generalized Anxiety Disorder
As noted in this chapter, the concept of challenging worries through problem solving, cognitive restructuring, and worry exposure is not sufficient for all patients with generalized anxiety disorder. If we conceptualize worry as a reaction to an underlying affective state, then elimination of worry will be helpful to only those patients who have sufficient coping skills and strategies to deal with whatever states the worry exposes them to. That is, just as exposure is helpful in agoraphobia, most cognitive-behavioral treatments of panic work by providing coping skills that will be used instead of avoidance strategies. If some patients with generalized anxiety disorder are avoiding affect (), then simply eliminating the worry through relaxation and cognitive techniques will not work unless they are taught other strategies to deal with the triggers for the affect. Borkovec () recently proposed that interpersonal strategies () be tested in addition to cognitive techniques to determine whether processing of interpersonal difficulties facilitates activation and modification of affective structures (1986).
In a similar notion, we have recently been working on applying schema-focused therapy to those patients who have not responded to traditional cognitive-behavioral therapy (1994). This approach focuses on addressing underlying “early maladaptive schemas,” which theoretically influence current symptomatology. Schemas are defined as persistent beliefs one develops about the self, based on formative experiences (which are often recurrent). Negative or faulty interpretations of positive and negative life experiences may lead to lifelong cognitive, behavioral, and emotional patterns of interacting with others and the environment. Based on our observations of patients with generalized anxiety disorder, we hypothesize that they may have schemas that include unrelenting standards (the belief that one needs to be the best or perfect at everything he or she does), vulnerability to harm (the belief that the world is a dangerous place and one can easily be hurt in it), and emotional inhibition (the belief that expressing one’s emotions is dangerous to the self or others and must be prevented). We have previously hypothesized that cognitive-behavioral therapy nonresponders may be patients who fit into the characterological model of generalized anxiety disorder, and, thus, an approach that focuses on these core issues may be warranted (1994). However, it is important to note that at this point, this is based on our clinical experience and not research data. Our recommendation for treating generalized anxiety disorder is to begin with the standard cognitive-behavioral therapy approach and to apply the schema-focused approach to those patients who have not responded.
Conclusion of Therapy for Generalized Anxiety Disorder
A considerable amount of progress has been made in the treatment of generalized anxiety disorder, especially considering that it only recently became a formal Axis I disorder. The progress is in part a result of the refinement in the diagnosis through the development of DSM III-R and DSM-IV, which has allowed for more accurate diagnosis. In addition, advances in the understanding of the nature and function of worry have allowed investigators to develop treatments that directly target these mechanisms. Some of the most innovative work to further increase the effectiveness of cognitive-behavioral therapy is focusing on facilitating emotional and interpersonal processing of information. The direction of the future appears to be initially treating patients with cognitive-behavioral therapy and then following up with interpersonal and affective techniques in nonresponders. If assessment allows for prediction of nonresponders, alternative methods of combination may be fruitful. At present, we await the data to make conclusions about these promising methods.