Cognitive Therapy of Anxiety Disorders

438 TREATMENT OF SPECIFIC ANXIETY DISORDERS

Clinician Guideline 10.27

Muscle relaxation training is a treatment option that may be employed when somatic anxiety

is so intense that the individual with GAD is unable to collaborate in cognitive interventions

for pathological worry.

effiCaCy of Cognitive therapy for gaD

The effectiveness of treatment for GAD may be lower than the rates reported for other
anxiety disorders. In his review Fisher (2006) concluded that cognitive- behavior therapy
that combines applied relaxation and cognitive therapy produces a 50% recovery rate
based on the PSWQ and a 60% recovery rate on the State–Trait Anxiety Inventory—
Trait Scale. In their meta- analysis of CBT, Gould et al. (2004) found that CBT for GAD
produced large effect sizes (i.e., 0.73) but only a few individuals attain a “well status.”
Likewise Hollon et al. (2006) noted that treatment gains for CBT are significant and
maintained over time but “there is a general sense that more can be done with the treat-
ment of GAD” (p. 300).
How effective is cognitive therapy for GAD? Several well- designed outcome stud-
ies have addressed this question. In one of the earliest outcome studies conducted on a
small GAD sample, group CBT and anxiety management showed more consistent and
significant improvement in anxiety compared with a benzodiazepine and wait list con-
trol group (Lindsay, Gamsu, McLaughlin, Hood, & Espie, 1987). Durham and Turvey
(1987) found that cognitive therapy and behavior therapy produced similar posttreat-
ment improvement in 50–60% of patients, but at 6-month follow-up significantly more
individuals from the cognitive therapy condition were improved (62%). In a later study
57 individuals with DSM-III-R GAD were randomly assigned to CBT, behavior therapy
(progressive muscle relaxation and graded exposure), or a wait list control (Butler et
al., 1991). CBT proved superior to behavior therapy, with 32% of individuals achieving
clinically significant change at posttreatment and 58% at 18-month follow-up compared
with 5% and 21%, respectively, for the behavior therapy group. Fisher and Durham
(1999) reviewed recovery rates based on the State–Trait Anxiety Inventory—Trait Scale
change scores in six randomized controlled trials and concluded that individual CBT
is one of the most efficacious treatments for chronic worry and GAD, with 6-month
follow-up improvement rates of 75% and actual recovery rates of 51%.
These positive outcome results for CBT have also been reported in more recent
studies. In a version of cognitive therapy that focused specifically on the cognitive fea-
tures of worry such as correction of erroneous worry beliefs, modification of intoler-
ance of uncertainty beliefs, and correction of a negative problem orientation, cognitive
therapy produced statistically and clinically significant change compared to a wait list
condition at posttreatment and 12-month follow-up with 77% of patients no longer
meeting criteria for GAD (Ladouceur, Dugas, et al., 2000). This finding was later rep-
licated with a group version of cognitive therapy, with 95% of the cognitive therapy
group no longer meeting diagnostic criteria for GAD at 2-year follow-up (Dugas et al.,
2003). However, there is evidence that older individuals with GAD do not show as good
a response to cognitive therapy or CBT for GAD as younger patients (Covin, Ouimet,