440 TREATMENT OF SPECIFIC ANXIETY DISORDERS
viduals with GAD who have a poor prognosis (high disorder complexity and symptom
severity) do not benefit significantly from more intense CBT (Durham et al., 2004).
Finally, the benefits of CBT for GAD may have broader application than amelioration
of chronic worry. In a recent study individuals with GAD randomly assigned to CBT
plus gradual medication tapering maintained their discontinuation of benzodiazepines
at 12-month follow-up (64.5%) significantly better than individuals (30%) who received
nonspecific treatment plus gradual tapering (Gosselin, Ladouceur, Morin, Dugas, &
Baillargeon, 2006).
Clinician Guideline 10.28
Cognitive therapy and cognitive- behavioral therapy are effective treatments for GAD that
achieve a posttreatment recovery rate of 50–60%. The treatments are highly effective in
reducing the pathological worry that characterizes GAD. There is evidence of long-term
maintenance of treatment effects, although most individuals will continue to experience
some symptoms and even meet diagnostic criteria. Older individuals with GAD may not
respond as well to cognitive therapy or CBT and the treatments are at least as effective as
pharmacotherapy or applied relaxation training. Overall the effectiveness of cognitive ther-
apy for GAD may be more variable and limited than cognitive therapy for other anxiety
disorders.summary anD ConClusionGAD has been referred to as the “basic anxiety disorder” (Roemer et al., 2002). Its car-
dinal feature is excessive, pervasive worry or apprehensive expectation about a number
of concerns or situations that occurs more days than not for at least 6 months and is dif-
ficult to control (DSM-IV-TR; APA, 2000). Over the years the diagnostic focus in GAD
has shifted from an emphasis on anxiety and its symptoms to the cognitive component
of anxiety (i.e., worry). An elaborated cognitive model of GAD was presented (see Fig-
ure 10.1) in which unwanted automatic intrusive thoughts of uncertain threat about
future events or situations activate prepotent generalized threat and vulnerability sche-
mas, resulting in hypervigilance and preferential processing of threat that prime elabo-
rative processes involving a reappraisal of threat and personal vulnerability or helpless-
ness. This sustained reappraisal or worry process becomes a self- perpetuating cycle that
intensifies schematic threat activation because of associated maladaptive metacognitive
processes. Worry itself becomes viewed as a dangerous and uncontrollable process, with
deliberate attempts at worry suppression proving unsuccessful. Moreover, the failure
to attain problem resolution or a sense of safety further reinforces the loss of control
associated with worry. The process degenerates into a maladaptive cognitive avoidance
strategy whose only success is the continued activation of dysfunctional schemas and an
information- processing system preferentially biased toward threat.
Empirical support for the cognitive model is mixed. There is considerable evidence
that GAD is characterized by (1) worry content related to an individual’s personal striv-
ings and current concerns; (2) schemas about general threat, vulnerability, uncertainty,