Worry and Generalized Anxiety Disorder

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

6.19 Worry and Generalized Anxiety Disorder THOMAS D. BORKOVEC and MICHELLE G. NEWMAN Pennsylvania State University, University Park, PA, USA 6.19.1 NORMAL AND PATHOLOGICAL WORRY

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6.19.2 DIAGNOSTIC DESCRIPTION OF GENERALIZED ANXIETY DISORDER

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6.19.3 IMPORTANCE OF GAD

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6.19.4 BASIC RESEARCH ON THE NATURE, FUNCTIONS, AND ORIGINS OF WORRY AND GAD

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6.19.4.1 GAD and Information Processing 6.19.4.1.1 Worrisome thinking and emotional processing 6.19.4.1.2 Worrisome thinking and other information processing functions 6.19.4.2 The Psychophysiology of GAD 6.19.4.3 GAD and Interpersonal Factors 6.19.4.3.1 GAD and early childhood interpersonal factors 6.19.4.3.2 GAD and adult interpersonal factors 6.19.5 THERAPY OUTCOME INVESTIGATIONS OF GAD 6.19.5.1 Review of Past Controlled Therapy Outcome Studies of GAD 6.19.6 CLINICAL DESCRIPTION OF COGNITIVE-BEHAVIORAL THERAPY FOR GAD 6.19.6.1 6.19.6.2 6.19.6.3 6.19.6.4 6.19.6.5 6.19.6.6

Self-monitoring and Early Cue Detection Stimulus Control Methods Relaxation Methods Applied Relaxation Self-control Desensitization Cognitive Therapy

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6.19.7 SUMMARY AND IMPLICATIONS FOR FUTURE THERAPY DEVELOPMENT

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6.19.8 REFERENCES

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6.19.1 NORMAL AND PATHOLOGICAL WORRY

mental problem solving on an issue whose outcome is uncertain but contains the possibility of one or more negative outcomes. Consequently, worry relates closely to fear processº (Borkovec, Robinson, Pruzinsky, & DePree, 1983a). So the early theoretical view of worry was that it was a cognitive avoidance response to detected threat (Borkovec, Metzger, & Pruzinsky, 1986). Several studies indicated that worry was indeed functionally separate from somatic anxiety and that it was primarily responsible for the interfering effects of anxiety

Research on worry began in the test anxiety area in the 1970s, where the distinction was made between worry as a cognitive aspect of anxiety and emotionality reflecting the physiological features of anxious experience. An early definition of worry suggested that it involved ªa chain of thoughts and images, negatively affect laden and relatively uncontrollable. The worry process represents an attempt to engage in 439

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on test and grade performance (Deffenbacher, 1980). During the 1980s, experimental research devoted to exploration of the nature of the worry process began. Inductions of worry were found to produce several important effects: incubation of negative thought intrusions (Borkovec et al., 1986; Pruzinsky & Borkovec, 1990; York, Borkovec, Vasey, & Stern, 1987), lengthening of decision-making times (Metzger, Miller, Cohen, Sofka, & Borkovec, 1990) due to elevated evidence requirements (Tallis, Eysenck, & Mathews, 1991), absence of change in heart rate (Borkovec et al., 1983a; York et al., 1987), elimination of the incubating effects of unconditional stimulus rehearsal in the unconditioned stimulus revaluation phenomenon (Davey & Matchett, 1994), and the generation of predominantly anxious but also depressive affect (Andrews & Borkovec, 1988). Remarkably, nonanxious groups displayed the very same effects during or after brief elicitation of the worry process. Related research indicated that anxious thoughts were harder to dismiss than neutral or depressing thoughts or intrusive negative images. Such research also showed that both the degree of worry about anxious thoughts and the presence of depressed states could further decrease control over anxious thoughts (Clark, 1986; Clark & DeSilva, 1985; Edwards & Dickerson, 1987a, 1987b; Sutherland, Newman, & Rachman, 1982). What generally emerged from this literature was that normal negative intrusive thoughts (including those of worry) were distinguishable from the pathological worry found in anxiety disorders by neither their process nor effects but rather by their frequency and intensity, which in turn appeared to be due to their uncontrollability (Clark, 1986; Clark & DeSilva, 1985; England & Dickerson, 1988; Kent & Jambunathan, 1989; Parkinson & Rachman, 1981; Salkovskis & Harrision, 1984). Despite growing interest in the phenomenon of worry during this period, the greatest boost to its investigation occurred when worry became the central defining feature of generalized anxiety disorder. 6.19.2 DIAGNOSTIC DESCRIPTION OF GENERALIZED ANXIETY DISORDER The diagnostic description of generalized anxiety disorder (GAD) has undergone several changes in diagnostic definition. The label first occurred in the third edition of the Diagnostic and statistical manual of mental disorders (DSM, American Psychiatric Association, 1980); the older category of anxiety neurosis was divided into panic disorder and GAD. The definition of

GAD focused on chronic, diffuse anxiety and its symptoms of apprehensive expectation (worry), vigilance/scanning, motor tension, and autonomic hyperactivity. If other Axis I conditions were present, however, GAD was not to be diagnosed. The arrival of DSM-III-Revised (American Psychiatric Association, 1987) was an important turning point. GAD was allowed as a principal diagnosis even in the presence of most other disorders, and it was centrally defined as apprehensive expectation (worry). Its remaining symptoms were organized into an 18-item checklist and designated as associated characteristics. Further revision occurred in DSM-IV (American Psychiatric Association, 1994) based on comprehensive reviews of the extant empirical literature on GAD (Borkovec, Shadick, & Hopkins, 1991). The disorder is now defined by excessive and uncontrollable worry about a number of events or activities not confined to other Axis I disorders, occurring more days than not for at least six months, causing clinically significant distress or impaired functioning, and not due to the direct physiological effects of a substance or a general medical condition. The associated symptoms checklist was reduced in size, based on empirical identification of the most frequent and reliable symptoms (Marten et al., 1993). Diagnosis requires the presence of only three of six symptom groups (restless/ keyed-up/on-edge, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance). Interestingly, all six symptoms reflect central nervous system (CNS) rather than autonomic nervous system (ANS) activity, matching what has been discovered in the psychophysiology of GAD. Also of importance for the scientific generalizability and continuity of GAD research, clients who meet GAD criteria by DSM-III-R routinely meet DSMIV criteria as well (Abel & Borkovec, 1995). 6.19.3 IMPORTANCE OF GAD GAD may be a particularly important area of experimental outcome and basic research. In terms of psychopathology: (i) estimates in the 1990s (Kendler, Neale, Kessler, Health, & Eaves, 1992; Wittchen, Zhao, Kessler, & Eaton, 1994) suggest 3.6±5.1% lifetime and 3.1% oneyear prevalence rates, and it is one of the most common comorbid conditions in the anxiety and mood disorders (Brown & Barlow, 1992); (ii) it may be the basic anxiety disorder (based on its early onset, chronicity, and resistance to change) out of which other anxiety disorders often emerge (Brown, Barlow, & Liebowitz, 1994); (iii) worry, the central feature of GAD, is

Basic Research on the Nature, Functions, and Origins of Worry and GAD pervasive in the anxiety and mood disorders (Barlow, 1988); (iv) worry has been experimentally demonstrated to prevent emotional processing and thus may maintain any disorder wherein such processing is important for therapeutic change (Borkovec, 1994); and (v) successful treatment of GAD results in dramatic reduction in comorbid conditions (Borkovec, Abel, & Newman, 1995). So understanding the mechanisms of GAD and developing effective therapies based on that understanding may not only contribute to the amelioration of a very common disorder which is difficult to treat but may also have significant implications for the treatment and/or prevention of other disorders. Investigation of GAD is also important in the more general pursuit of understanding human nature and its adaptive and maladaptive processes. Research on GAD and worry has implicated the mutually interactive influences of several response systems (e.g., attention, interpretation of the environment, implicit and explicit memory, abstract thought, imagery, affect, central and peripheral physiology, and behavior) in their processes and maintenance. Thus, the study of GAD may yield knowledge in general, about the nonlinear dynamical nature of human functioning, viewed as a constantly changing process in response to a changing environment. Finally, recent basic research on GAD, especially on the role of developmental and interpersonal factors, holds considerable promise for the development of more effective therapy. 6.19.4 BASIC RESEARCH ON THE NATURE, FUNCTIONS, AND ORIGINS OF WORRY AND GAD Clinical experience and empirical results suggest a straightforward description of the inner life of GAD clients: it is necessary to search constantly for cues about possible future threat (ªWhat if . . .?º) in order to avoid catastrophes or to prepare ways to cope with their occurrence (Beck & Emery, 1985). Because the dangers exist only in their minds and only in the future, behavioral avoidance is not an available response. This leaves conceptual activity (i.e., worry) as one of the few coping resources. Human thought may well have evolved specifically to anticipate the future, to avoid negative events, and to increase positive events (McGuire & McGuire, 1991). The central questions for GAD research, however, focus on why so much threat is perceived, what the specific nature, functions, and consequences of the pathological worry response to threat might be, what factors are involved in its origins and

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maintenance, and how it is best treated. Results suggest that the answers will likely be found in dysfunctional processes within and interactively between three domains: information processing, physiology, and interpersonal functioning. 6.19.4.1 GAD and Information Processing Evidence indicates that GAD and its central worry feature are associated with impairments in several types of information processing, the most important of which is the processing of emotional material. 6.19.4.1.1 Worrisome thinking and emotional processing When people worry, they are mostly talking to themselves. Worry involves a prevalence of abstract, verbal-linguistic, thought as opposed to imaginal process (Borkovec, 1994). This is true for GAD clients and nonanxious controls when they are worrying. During relaxation states, GAD clients continue to experience the predominance of thoughts, whereas nonanxious persons shift to a predominance of imagery. Therapy for GAD clients leads to the normalization of thought and image frequencies (Borkovec & Inz, 1990). The extensive findings on the role of such cognitive factors and many others in GAD (Mathews; 1990; Mathews & MacLeod, 1994) has long suggested the usefulness of cognitive therapy (CT) for the disorder. The role of such cognitive factors is also fundamental to a specific theoretical view of the nature and functions of worry. The distinction between thought and imagery is crucial. Imagery is closely tied to efferent commands into the affective, physiological, and behavioral systems; thought is not. Imagination of fear material elicits strong cardiovascular response; verbally articulating the same material does not (Vrana, Cuthbert, & Lang, 1986). It is adaptive that thought evolved in this way. Its relative isolation from efferent systems increases choice and flexibility. Worrisome thought, however, has the disadvantage that it precludes emotional processing. Phobic persons who think worrisome thoughts just prior to repeated phobic image presentations show no cardiovascular response at all to those images; those who think neutral or relaxing thoughts display significant response, with relaxation producing habituation over repeated images (Borkovec & Hu, 1990; Borkovec, Lyonfields, Wiser, & Diehl, 1993a). Moreover, worry after exposure to a stressful event also results in a failure to process the emotional material adaptively (Butler, Wells, &

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Dewick, 1995; Wells & Papageorgiou, 1995). From a neobehavioristic perspective, absence of cardiovascular response to phobic information reflects a failure to access the complete fear structure stored in memory (especially its efferent emotional meanings) and therefore an absence of the kind of emotional processing necessary for extinction (Foa & Kozak, 1986). One of the immediate functions of worry, then, is the avoidance of aversive images, somatic anxiety, and other negative emotions, and the worrying is thereby strengthened via negative reinforcement. A significant consequence of this avoidance function is the maintenance of anxious meanings despite daily exposures to threat-related material and the potentially corrective information that accompanies such exposures. These findings and their theoretical context have long suggested the usefulness of imagery exposure (combined with relaxation) for accessing and changing emotional meaning in therapy for GAD. The above research supports the hypothesis that worry functions as a cognitive avoidance response to threatening material. Analogue GAD and control groups actually view worry in a similar way (Borkovec & Roemer, 1995). When these groups rated possible reasons for worry, only one scale discriminated the two groups: ªWorrying about most of the things I worry about is a way to distract myself from worrying about even more emotional things, things that I don't want to think about.º Although this could merely represent attempts of the GAD participants to rationalize why they worry, it may also reflect a further avoidance function of worry: avoidance of more painful emotional material. Rather than focus on primary affect, the superficial content of worry may be focused on secondary or instrumental affects. What underlying content might be avoided is speculative, but three candidates exist, and all relate to interpersonal issues. Two (negative attachment experiences and current interpersonal problems) are discussed later. The third possibility resides in the fact that both GAD clients and analogue GAD groups report more frequent past traumas than controls, and 65% of these are interpersonal in nature (Roemer, Borkovec, Posa, & Lyonfields, 1991). Of course, when considering this evidence, we must be mindful that recall is subject to distortion, the traumas could have occurred after the onset of GAD, and many psychiatric groups report frequent trauma. However, content analyses of the trauma topics and worry topics reveal indirect evidence for avoidance of trauma memories (Shadick, Roemer, Hopkins, & Borkovec, 1991). Even though the traumatic

events involved death, illness, or injury related to self or others (as required by DSM trauma definition), this is the very category about which GAD clients worried the least. The avoidance of trauma content can in and of itself lead to the maintenance of anxious meanings, but a traumatic experience may also provide actual evidence that the world (especially involving other people) can indeed be a threatening place and further contribute to the origins and/or maintenance of GAD. The implication of worry's function as cognitive avoidance and its prevention of emotional processing is far-reaching. Worry contains a process that maintains GAD or indeed any emotional disorder. Emotional change due to daily life experiences or to deliberate exposures in therapy to emotional material is less likely to take place to the degree that worry is present before, during, or after such exposures. The mechanisms for worry's inhibitory effect on emotional processing are unsubstantiated, but four possibilities have been suggested (Borkovec, 1994): (i) lessened attentional resource for processing other information (Mathews, 1990); (ii) difficulty of shifting attention from excessive, habitual (especially negatively valanced) thought activity (Parkinson & Rachman, 1981); (iii) semantic satiation effects of repetitious worrisome thought, thus insulating worry content from the rest of its associative network, especially affective associations (Smith, 1984); and (iv) less mismatch between information expected and received (a central condition for anxiety in Gray's neuropsychological theory of anxiety (Gray, 1982)). Future basic research might aim usefully at isolating the specific mechanisms involved. 6.19.4.1.2 Worrisome thinking and other information processing functions Research evidence indicates that GAD and worry are associated with various information processing characteristics that interfere with learning from experience and thereby maintain anxious meaning. GAD clients display (i) preattentive bias to threat cues, even outside of awareness and often with task-interfering effects, (ii) rapid cognitive avoidance of detected threats such that explicit memory for the material is reduced but implicit memory is increased, and (iii) negative interpretations of and predictions from ambiguous and even neutral information. Several of these effects are accentuated for stimulus material directly associated with the client's worrisome concerns (Mathews, 1990; Mathews & MacLeod, 1994). Three further instances of worry effects on information processing have emerged. First, in

Basic Research on the Nature, Functions, and Origins of Worry and GAD the current therapy trial at the Pennsylvania State GAD Project, clients monitor their daily worry predictions and rate actual outcomes once they occur. In this study, the outcomes turned out better than expected 84% of the time, and in 78% of the remaining situations, clients still coped better than they predicted. Thus, in only 3% of all worries did the core feared event (ªThe predicted bad event will occur, and I won't be able to cope with itº) actually happen. It is possible that GAD clients continue to worry despite consistent real world evidence that feared outcomes do not occur because they frequently fail to process this corrective evidence. Second, people who worry about a topic prior to generating alternative predictions of what might happen generate exclusively negative predictions, whereas people who relax before generating the alternatives list only positive predictions (Borkovec, 1995). This suggests that worrying increases cognitive rigidity and that this rigidity precludes the retrieval of realistic corrective information. Third, several studies have demonstrated poor recall (reflecting cognitive avoidance) of threat words in GAD (cf. Mathews, 1990). However, a study by Thayer and Borkovec (1995) attempted to replicate these findings using a higher-order classical conditioning task (i.e., emotional words as the unconditional stimuli). In this study, GAD clients were exposed to 10 threat words (preceded by a colored block, the conditional stimulus) and 10 nonthreat words (preceded by a differently colored block) in random order. Clients merely read the words silently as they appeared, but they were given a surprise recall task at the end. Contrary to results of prior research, clients recalled more threat than nonthreat words and to a greater degree than nonanxious participants. Whereas previous research was based on brief exposures and/or instructions to actively respond to the words, Thayer and Borkovec used a longer exposure time. This suggests that lengthier exposures during a passive task will enhance threat recall from explicit memory, perhaps by overriding the defensive process of cognitive avoidance. Taken as a whole, the above research indicates that GAD is characterized by habitual, inflexible cognitive and affective processes. A parallel rigidity has also been found in the tonic physiology of GAD and the phasic physiology of worry. 6.19.4.2 The Psychophysiology of GAD Unlike the results from other anxiety disorders, physiological activation is not always characteristic of GAD, and inductions of worry

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do not produce differential activation compared to relaxed states (Borkovec et al., 1983b; Elliott, 1990). One study did find greater CNSmediated muscle tension in GAD but no other activation differences compared to controls (Hoehn-Saric, McLeod, & Zimmerli, 1989). However, GAD was characterized by reduced variability in autonomic measures, leading to the hypothesis that GAD involves sympathetic inhibition and an autonomic inflexibility rather than sympathetic activation (Hoehn-Saric & McLeod, 1988). Rigid autonomic functioning is implicated in several biological disorders (Thayer, Friedman, & Borkovec, 1996). Models of nonlinear dynamical systems view flexible responding as a marker of system integrity, and these models interpret reduced variability to be pathological (Goldberger, 1992). The hypothesis that GAD is characterized by a distinctive physiology involving restricted range of variability thus takes on added importance. However, the speculation that this is due to sympathetic inhibition may be an oversimplification of complex autonomic activity which involves both sympathetic and parasympathetic branches. Evidence supports the specific importance of chronic parasympathetic (vagal) deficiency in GAD. Analogue GAD participants display tonically lowered vagal tone and little variation in either vagal tone or heart rate during rest, aversive imagery, and worrisome thinking (Lyonfields, Borkovec, & Thayer, 1995). Nonanxious participants show decreases in vagal tone from rest to emotional tasks and the greatest reduction during worry. Thus, GAD is characterized by autonomic inflexibility, such rigidity is due to a chronic deficiency in parasympathetic tone, and worrisome thinking can cause such reductions. Replicated findings emerged from a comparison of GAD clients to nonanxious participants during periods of selfrelaxation and worry (Thayer et al., 1996). GAD was characterized by a tonic deficiency in vagal tone, and a main effect of tasks indicated that worry phasically caused that deficiency in GAD and nonanxious participants. These results make dramatic sense if we combine what is known empirically about GAD (e.g., chronic vigilance to threat, frequent aversive cognitions with a predominance of worrisome thought, excessive muscle tension, and difficulty concentrating) with results from experimental physiology: tasks that phasically cause reduced vagal tone among normals include threat of shock, recall of past aversive events, mental problem-solving, and isometric hand-grip (Grossman, Stemmler, & Meinhardt, 1990; Grossman & Svebak, 1987). Moreover, vagal deficiency provides a physiological basis for the

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habitual, GAD-characteristic attentional processes mentioned previously, given that poor attentional concentration and distractibility are related to lower vagal tone in both infants (Richards, 1987) and adults (Porges, 1992). The above research demonstrating vagal deficiency and autonomic inflexibility in GAD reinforces the long-held view of the usefulness of relaxation methods in the treatment of GAD. These results also provide a clear physiological basis for the finding that CNS but not ANS symptoms characterize the self-reports of GAD clients (Marten et al., 1993). This GAD-distinctive inflexibility also makes sense when considering the psychological situation that GAD clients face. Their threats are illusory, exist only in their minds, refer to a nonexistent future, and are based on fears of events having a low probability of occurrence. The clients thus face an insoluble problem wherein fight-or-flight activation is inhibited because there is no one to fight and nowhere to flee, analogous to the freezing response of rats when motoric avoidance to feared stimuli is prevented. Electroencephalogram (EEG) differences have also been discovered between nonanxious groups and both GAD clients and chronic worriers (e.g., greater frontal beta and less parietal alpha for the latter) as well as between relaxation and induced worry tasks (e.g., greater frontal and parietal beta during worry) (Carter, Johnson, & Borkovec, 1986; Inz, 1990). Importantly, inflexibility was also revealed in the cortical activity of GAD clients; lowered variability was found in alpha and beta over several laboratory tasks (Inz, 1990). Although restricted, tonic cardiovascular functioning appears to be characteristic of GAD, a close look at phasic heart rate reactions to threatening material reveals that brief initial activation can occur. Results from the threat/ nonthreat word conditioning task described earlier have shown that: (i) nonanxious participants showed larger orienting responses to threat and nonthreat words than GAD clients; (ii) their magnitude was related to resting vagal tone (described earlier to be deficient in GAD and intimately related to attentional mechanisms); (iii) the control group, but not GAD group, showed habituation of physiological response over both threat and nonthreat trials; (iv) GAD clients, but not the control participants, displayed heart rate acceleration (the classic ªdefensive responseº) to threat words; and (v) the GAD group, but not the control group, developed an anticipatory heart rate deceleration to the colored block preceding threat words but not to the block preceding nonthreat words (Thayer & Borkovec, 1995).

The latter result indicates that classically conditioned orienting responses (indicating increased attention) emerge in GAD over repeated exposures to verbal threat material, and provides a basis both for GAD hypervigilence and for the generalization of threatening meaning via associative learning processes which depend solely on words as the unconditional stimulus. These results may have significant implications for understanding the interrelationships between the processing of verbal material, attention, associative emotional learning, and physiology in GAD. Thus far, we have reviewed information on the intrapsychic patterns of GAD showing inflexible and repetitious cognition, affect, and physiology. Several lines of research have also explored the possibility of habitual patterns in overt behavior, particularly those in the domain of interpersonal functioning. Such research has found evidence for recurrent, problematic, interpersonal behavior as well as for possible connections between adult interpersonal styles and early attachment experiences. 6.19.4.3 GAD and Interpersonal Factors For many years, researchers have known of a significant connection between GAD and interpersonal factors. Several lines of evidence have contributed to this knowledge. First, patterns of familial history in GAD (Noyes, Clarkson, Crowe, Yates, & McChesney, 1987; Noyes et al., 1992) along with a low degree of heritability (Kendler et al., 1992; Torgersen, 1986) imply that interpersonal developmental experiences may provide some etiologic foundation for GAD. Second, although GAD clients worry about many topics, they are particularly afraid of interpersonal situations: social phobia is the most frequent comorbid diagnosis for GAD (Barlow, 1988; Borkovec et al., 1995); trait-worry correlates more highly with social fears than with nonsocial fears (Borkovec et al., 1983b); content analysis of GAD worry topics reveals interpersonal concerns to be more frequent than any other domain (Shadick et al., 1991). Finally, worry involves a predominance of thought; thought is based upon language; language is based on social communication. Thus, some features of thought (talking to ourselves) are inherently interpersonal (Borkovec et al., 1991). Together, these observations suggest that a history of negative interpersonal experiences may contribute to the origins or maintenance of GAD, to current interpersonal functioning, to the maintenance of an excessive perception of threat, and/or to learned worrisome thought styles to cope with threat.

Therapy Outcome Investigations of GAD 6.19.4.3.1 GAD and early childhood interpersonal factors Bowlby (1982) was quite specific about hypothesized relationships between attachment and anxiety. If a child has a primary attachment figure who is repeatedly unavailable, the resulting insecure base may manifest itself in the child's developing mental models of the world as a dangerous, frightening place, with an overestimation of the probability and severity of feared events and an underestimation of coping resources. These mental representations are strikingly similar to those present in adult GAD. Indeed, diffuse anxiety was felt by Bowlby to be the typical consequence of some forms of insecure attachment. The Inventory of Adult Attachment (IAA, Lichtenstein & Cassidy, 1991) is based on Main and Goldwyn's (in press) system for scoring their Adult Attachment Interview (George, Kaplan, & Main, 1985) and on Bowlby's attachment theory. Results using the IAA indicate that the GAD groups score higher than nonanxious groups on role-reversed/ enmeshed relationships but not on childhood rejection (Borkovec, 1995). The child had to take care of the parent rather than the parent taking care of the child. This suggests an understandable basis for the adult GAD view of the world as a potentially dangerous place, of oneself as unable to cope, and of the need to constantly anticipate threats as the necessary means to obtain love, approval, and nurturance. The clients also reported greater unresolved feelings of anger and vulnerability toward their primary caregiver. Both the enmeshment and anger/vulnerable findings are discussed more fully below in relation to findings on adult interpersonal styles. Finally, the GAD group reported greater difficulty remembering their childhood. Whether the latter reflects motivated cognitive avoidance of negative memories or the fact that GAD clients have a harder time remembering anything due to the sheer amount of conceptual activity in which they are constantly engaging is not yet known. 6.19.4.3.2 GAD and adult interpersonal factors Clinicians often discover that many of the concerns raised by their GAD clients relate to interpersonal relationships. Research at the Pennsylvania State Project (Pincus & Borkovec, 1994) has made use of the Inventory of Interpersonal Problems Circumplex Scales (IIP-C, Alden, Wiggins, & Pincus, 1990) to assess the interpersonal functioning of GAD clients in a psychometrically sound way. Results indicate that GAD clients show not only greater

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interpersonal distress (not surprisingly) but also a greater rigidity in their interpersonal styles across differing situations than nonanxious people (Pincus & Borkovec, 1994). Thus, GAD has now been shown to reflect inflexibility in cognitive, affective, central physiological, peripheral physiological, and interpersonal behavioral domains. More importantly, cluster analysis has revealed three subtypes of GAD, replicated in both initial and cross-validation samples. The first of the two smaller clusters (24.3% of the clients) involved social avoidance and nonassertiveness, whereas the second cluster (13.5%) was characterized by elevated domineering and vindictive scales. The primary interpersonal problems for GAD (62.1% of the clients) were found on the overly nurturant and intrusive scales. Relating this to the attachment results, the majority of GAD clients may have learned in childhood to care for others in order to get love, approval, and nurturance, and they may continue to repeat this pattern in adulthood for the same reason. Worry may thus function, as it did in childhood, as a means of anticipating the needs of, and threats to, significant others in the pursuit of satisfying interpersonal needs. The discovery of this majority cluster, along with the attachment results, also fits well with research (Peasley, Molina, & Borkovec, 1994) showing that GAD groups report higher degrees of empathy on the Interpersonal Reactivity Index (Davis, 1980). This empathy was most prevalent in the realm of feeling other people's pain. Thus, attempts by GAD clients in the overly nurturant cluster to take care of others may also be motivated by attempts to reduce one's own pain caused by intensely feeling the pain of others. 6.19.5 THERAPY OUTCOME INVESTIGATIONS OF GAD Although the findings on the possible role of interpersonal factors in GAD suggest that such factors may become a very important feature in the future development of more effective therapies, all controlled therapy outcome investigations to date have involved evaluations of behavioral and cognitive-behavioral therapy (CBT) treatments that target intrapersonal anxiety process. 6.19.5.1 Review of Past Controlled Therapy Outcome Studies of GAD Systematic development and evaluation of psychotherapies for GAD began only recently for two reasons. First, GAD has historically been an ambiguous disorder with frequent

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changes in diagnostic definition. Second, the etiology of GAD was not well explained by the discrete conditioning events that have been used to elucidate the origins of other anxiety disorders. Moreover, because conditioned environmental triggers for anxiety were not obvious, and internal cues were more functionally relevant, the utility of exposure methods was less clear for the diffuse forms of anxiety found in GAD. Thus, early treatments for GAD emphasized the somatic aspects of the client's anxiety and trained clients to use relaxation techniques as a general coping response whenever they felt anxious. Later developments involved the addition of elements from behavioral self-control and cognitive treatments. These elements included an emphasis on thorough applied relaxation training (OÈst, 1987), rehearsal of relaxation and cognitive coping responses during imaginal exposures to environmental and internal fear cues (e.g., selfcontrol desensitization (Goldfried, 1971), anxiety management training (Suinn & Richardson, 1971), and CT aimed at modifying the GAD client's constant perception of threat (Beck & Emery, 1985). The emerging view of GAD, based on growing evidence concerning its nature and the specific functions of worry, now sees it as a loosely structured cognitive-affective state (Barlow, 1988) whose process is characterized by spiraling, habitual, inflexible interactions of multiple systems responding to constantly perceived threat (Borkovec & Inz, 1990). Thus, intrapersonally focused CBT was designed to provide multiple coping responses for the targeting of each of the maladaptive reactions and their interactions and to replace anxietymaintaining spirals among these systems with alternative responses. Such a treatment should be able to help an individual to develop a flexible, adaptive lifestyle conducive to reduced anxious experience. Only 12 controlled outcome studies on DSMdefined GAD have been published. Review of 11 of these studies indicated that indeed CBT produces both statistically and clinically significant change, with maintained or increased improvement up to a year later (Borkovec & Whisman, 1996). This therapy has also been associated with low drop-out rates, declining use of psychotropic medication, and the largest degrees of change among contrasted therapies and control conditions on both anxiety and depression measures. Fifteen earlier outcome studies of ªgeneral anxietyº are consistent with the GAD trials: anxiety management has produced long-lasting gains that were sometimes superior to component conditions, and CT techniques may add to post-therapy and especially follow-up improvement (Durham &

Turvey, 1987; Lindsay, Gamsu, McLaughlin, Hood, & Espie, 1987). Finally, a twelfth GAD study found CBT to be superior to anxiety management at six-month follow-up and superior to brief psychodynamic therapy at posttherapy and follow-up (Durham et al., 1994). However, several methodological flaws render the conclusions questionable (brief duration of GAD, therapist-by-treatment confound, lower credibility for the psychodynamic condition, no therapy manuals, large drop-out rate, higher severity for the psychodynamic condition, and no therapy integrity checks). Despite these promising effects, three areas of concern exist (Borkovec & Whisman, 1996). First, the role of nonspecific factors or individual CBT components remained unclear until the late 1990s. Although placebo and individual elements have yielded less change than CBT, between-group effects have not always emerged. Second, clinically significant change for CBT has been moderate at best (50% high endstate functioning on average across studies). An earlier review of nine of these studies came to similar conclusions (Chambless & Gillis, 1993). Finally, although their methodology has been fairly good (e.g., frequent use of manuals, diagnostic interviews, integrity checks, and expectancy/credibility assessments), significant deficiencies exist in the majority of the studies. Most importantly, only three studies required two independent diagnostic interviews. Principal GAD has the lowest interassessor kappa among anxiety disorders (Barlow & DiNardo, 1991). Absence of independent diagnosis raises the possibility of false-positive cases (as many as 25±30%). Increased error variance due to falsepositive cases may explain why CBT has not always produced significantly greater improvement than nonspecific or component conditions and why prior basic research on GAD has often yielded ambiguous or conflicting results. Somewhat greater clarity on the issue of nonspecific effects and the contribution of individual CBT elements was achieved in a comparison of applied relaxation, CBT (applied relaxation, self-control desensitization, and brief CT), and a reflective listening control condition (Borkovec & Costello, 1993). Unlike many prior studies, this study required two independent diagnostic interviews, as well as quality and adherence checks of the therapy provided. At post-therapy, applied relaxation and CBT were superior to reflective listening, despite the fact that reflective listening was superior to the other two conditions on depth of emotional processing as objectively measured by the Experiencing Scale (Klein, Mathieu-Coughlan, & Kiesler, 1986). However, at 12-month follow-up, clients in the reflective listening

Clinical Description of Cognitive-behavioral Therapy for GAD condition had lost most of their gains and had more frequent subsequent therapy, clients in applied relaxation had maintained their gains, and those in the CBT condition showed further gains and had higher endstate functioning (50% of the clients) compared to the other two conditions. These findings support the view that a cognitive behavioral treatment for a multidimensional disorder like GAD will be most effective if it targets each (cognitive, physiological, and imaginal) system found in basic research to play a significant role in GAD. The fact that reflective listening produced greater levels of emotional processing but failed to achieve a better outcome in the above trial suggests that the type of emotional processing that occurred was not therapeutically relevant to this disorder. From an experiential perspective, the primary affects most centrally involved in emotional disturbance are not easily accessed in GAD when reflective listening alone is provided; the avoidant function of worry may yield a client focus on secondary or instrumental affect (Greenberg & Safran, 1987). For emotional processing to occur, more potent techniques for accessing and deeply experiencing underlying, primary emotions in the present moment may be necessary. But the development of such a therapeutic focus, either for exposure treatment or for experiential techniques, must await future research which identifies what those primary fears might be in GAD. The current therapy study in the Pennysylvania State Project compares applied relaxation/self-control desensitization, CT, and their combination. Therapy time was increased by 50% to allow for more complete CT than in the previous trial. Preliminary results based on a partial sample have indicated that one-third of the clients in each of the three conditions reached high endstate functioning by the end of therapy. At both follow-ups, however, the combined CBT group had increased to a 50% rate, whereas the two single-element conditions lost endstate gains. Should these outcomes hold up once all clients have completed therapy, they will support the already existing trend in the outcome literature suggesting that long-term maintenance is indeed best produced by a combined CBT therapy that targets each of the intrapersonal anxiety response systems. However, it is also clear that the attempt to increase the efficacy of CBT by doubling therapy time was not successful. CBT outcome at follow-up was not significantly different from previous trials. This strongly suggests the wisdom of looking elsewhere to develop more powerful therapeutic approaches for GAD. Further preliminary results from this ongoing trial strongly suggest that this may well involve the

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therapeutic targeting of interpersonal problems (Borkovec, 1995). Three of the IIP-C scales that significantly contributed to the clustering results (domineering, overly nurturant, and intrusive) failed to change significantly after CBT. Most importantly, these three scales (plus the vindictive scale) negatively predicted outcome, and these relationships were stronger at follow-up than at post-test. Thus, interpersonal problems, if left unattended in therapy, may be especially associated with failure to maintain therapeutic gains obtained by intrapersonally oriented CBT. 6.19.6 CLINICAL DESCRIPTION OF COGNITIVE-BEHAVIORAL THERAPY FOR GAD Despite limitations in CBT, both in degree of improvement and failure to address potentially important interpersonal issues, it is the only therapy method for GAD which has been empirically validated (Chambless et al., 1996). This section will provide a clinical description of the CBT elements which are most frequently used in controlled trials with the disorder. The protocol treatments in these trials have depended on such basic resources as Beck and Emery's (1985) text on CT with anxiety disorders and Bernstein and Borkovec's (1973) manual on progressive relaxation training. The principles and techniques of those approaches will not be reviewed here in detail. Instead, the present section will describe clinical adaptations of basic behavioral and cognitive therapy methods specifically for GAD, adaptations which have often been guided by the basic empirical research on the disorder summarized earlier in this chapter. 6.19.6.1 Self-monitoring and Early Cue Detection Self-monitoring of anxiety cues on a momentto-moment basis is foundational to CBT with GAD. Although the identification of environmental cues is important, greater emphasis is placed on determining relevant internal cues that trigger anxiety and worry. The latter include attention, thoughts, images, bodily sensations (especially muscle tension), emotions, and behaviors. Human experience is described to the client as an active process involving the interaction of these internal cues as they respond to a constantly changing environment. Anxiety is the result of an incremental process that develops as each internal cue is triggered by other cues in a combined effort to respond to perceived threat.

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For example, a person has a thought, which triggers an emotion, and that emotion triggers another thought which triggers muscle tension, which leads to the spiraling up of anxiety. It is not our reactions to events that are the problem; the initial reaction is quite natural and understandable, given our past history of learning. The problem resides in our reactions to our reactions. These are the habits which we have developed and that are further strengthened each time we allow their entire sequence to occur. In therapy, the deliberate changing of reactions to our reactions and the strengthening of new coping responses in each relevant system are targeted. Emphasis is therefore placed on increasingly early detection of internal changes occurring in an anxious direction. The earlier we can identify incipient cues for anxiety, the earlier we can intervene. Any new intervention will be more effective in reducing anxiety if it is applied earlier in the spiral. Asking clients to describe typical anxiety experiences in terms of what they attend to, do, think, imagine, and somatically and emotionally feel is a good starting point. However, the use of imagery of past or upcoming anxietyprovoking situations can help clients more accurately identify the internal contents and sequences of actual anxious experience. The use of a repeated image can help clients attend to each relevant system and to practice the early detection of relevant cues. This in-session exercise also provides a concrete rehearsal of the very self-monitoring that clients are asked to practice in daily life. Of particular importance is the actual worry process. Asking clients to worry silently about a typical topic of concern allows them to observe and describe this process in a more objective way. Asking them to subsequently worry out loud is often useful as well. This exercise gives the therapist some hints about what the nature and content of worry are for a specific client. The therapist also observes clients for any detectable shift in their affective state and immediately asks them to describe what is occurring. In this way, the therapist serves the role of early detector of incipient anxious spirals and facilitates client recognition of early cues. Clients are encouraged to tell the therapist when they notice the beginning of anxiety cues. Such encouragement allows the therapist to fade out prompting as clients rehearse their own early detection, the very goal of self-monitoring in daily life. Clients are encouraged to practice selfmonitoring on a daily basis between sessions. Remembering to do so is the most difficult challenge, so the therapist provides a variety of suggestions for establishing reminders in the

client's environment (e.g., checking every halfhour, at every change in activity, and in response to noticing post-it notes placed in noticeable locations). Over time, increasingly specific reminder cues which are particularly suited to the anxiety process of individual clients can be identified and used (e.g., whenever the phone rings, whenever a particular co-worker or family member is first seen during the day, whenever the client notices foot-tapping or hair-twisting behaviors). The important thing is that a sufficient number of effective cues are established to frequently remind clients to observe their inner processes. The ultimate goals are to establish a habit of recognizing incipient anxiety and to intervene at that moment with whatever coping responses have been learned up to that point. Self-monitoring need not be focused only on anxiety cues. Both worry in general and GAD in particular are associated with other important emotional experiences (e.g., anger, frustration, depression) as well. Learning to detect the incipient cues for each of these emotional experiences and to distinguish them from anxiety will facilitate the application and mastery of interventions better suited to them and/or may lead to the identification of their functional role as the beginning point or consequence of an anxiety spiral. 6.19.6.2 Stimulus Control Methods Because it occurs in numerous situations, the worry process is usually under poor discriminative control. However, once clients have learned to detect the occurrence of worry, the therapist can introduce a very simple stimulus control method for reducing the amount of time spent worrying. A degree of stimulus control can be re-established by providing clients with five instructions. (i) Establish a 30-minute worry period to occur at the same time each day and in the same place (a place not associated with other daily activities). (ii) Learn to detect the worrying at earlier and earlier moments, with the goal to ultimately identify its onset. (iii) As soon as it is detected, postpone it to your worry period. Remember that you will have plenty of time to focus on your worry at that time and there is no need to make yourself miserable by worrying now when you have better things to do. Also keep in mind that short-circuiting worry will help reduce its habit strength. (iv) After postponing the worry, focus your attention on the present environment or the task at hand.

Clinical Description of Cognitive-behavioral Therapy for GAD (v) Use your worry period to worry intensely or (later in therapy) to employ some of the CT strategies to eliminate the source of the worrying. Although empirical support for the efficacy of this technique is available on college samples of chronic worriers (Borkovec, Wilkinson, Folensbee, & Lerman, 1983c), a full clinical trial to evaluate its usefulness in GAD samples has not yet been conducted. Clinical experience suggests, however, that this simple method can often provide some beginning relief fairly quickly. 6.19.6.3 Relaxation Methods Because autonomic inflexibility is characteristic of GAD physiological process, training in multiple relaxation methods for flexible application as well as to strengthen parasympathetic tone is desirable. Such relaxation methods can include paced diaphragmatic breathing, progressive muscle relaxation, guided imagery, meditation, and, most importantly, daily application of applied relaxation. Clients are encouraged to experiment with the different techniques in response to different response system reactions and to identity which ones are most helpful under which circumstances. With several coping responses available, the likelihood of finding an effective one in any given situation increases, and clients develop an increased sense of choice and flexibility as well. When new cognitive or behavioral techniques are introduced in therapy, it is helpful to do demonstrations wherein the clients' own deployment of strategies produces an immediate, noticeable, and positive effect, however slight. In this way, clients obtain a sense that the technique can make a difference for them with further practice and application. Slowed, paced, diaphragmatic breathing produces a rapid relaxation response with little training and can be immediately used in daily living. The therapist models and has clients imitate both rapid, shallow, thoracic breathing (a sympathetic elicitor) and slowed diaphragm breathing (a parasympathetic elicitor). In this way, clients learn that the way that they breathe affects how they feel and that they can exert some immediate control on physiological and psychological states merely by controlling respiration. Typical instructions for diaphragmatic breathing would be: ªShift to breathing from your stomach rather than from your chest. Allow your diaphragm to rise and fall without expanding your chest. Also, slow your breathing down to a rate slower than usual but not so slow that it is unpleasant or uncomfortable. You might do this by counting from one to three as you

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breathe in evenly and then again as you evenly exhale.º A few minutes of diaphragmatic breathing practice helps clients learn what relaxation feels like and how to elicit it quickly. They are encouraged to shift to this type of breathing whenever they notice thoracic breathing in order to develop diaphragm breathing as a habit. This coping response can also be used upon early cue detection during daily selfmonitoring as an initial method for learning to control anxiety spirals. Moreover, when the therapist cues the client to become aware of increased anxiety during the session, the therapist can ask them to apply this relaxation response for a brief moment to reduce those cues, thus giving clients immediate opportunities for rehearsing applied relaxation. Training in progressive muscle relaxation (PMR) involves systematically tensing and releasing various muscle groups throughout the body. This exercise causes a lengthening of muscle fibers which results directly in reduced muscular tension and indirectly in reduced sympathetic activity. Clients formally practice the technique twice a day to deepen their relaxation response and to strengthen their ability to generate it in daily applications. As therapy progresses, muscle groups are combined, and tension production is eventually replaced by relaxation-by-recall, wherein clients merely identify extant muscle tension and let go of that tension by recalling how those muscles felt when tension was produced and released. The notion of ªletting goº of muscular tension is inherent in PMR. Each time clients let go of tension in a particular muscle group, they become a little more relaxed. Once clients are accustomed to producing relaxation by concretely releasing muscular tension, the therapist can introduce the analogous notion of letting go of other processes involved in their anxiety spirals. For example, clients can also practice the gentle letting-go of distressing thoughts, worries, images, bodily sensations, and negative emotional experiences. They can be reminded that it is their reactions to their reactions that make a difference. Meditational techniques are often useful because they specifically emphasize attention to a single focusing device. Strengthening one's ability to shift attention away from anxietyprovoking cognitions to one pleasant, internal stimulus is particularly helpful for GAD clients whose mental life is often consumed with attention to worrisome thoughts and catastrophic images. The therapist can ask clients to use diaphragmatic breathing for this purpose, or they can work with the client to identify a specific image or word which taps into previous senses of safety, comfort, security, love, and/or

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tranquillity. The word, ªhome,º for example, for some clients may be associated with special, positive meaning. For other clients, interpersonal connections (e.g., an image of one's infant daughter) might serve this purpose. Clients are asked to practice meditational methods by focusing on the pleasant internal stimulus for a few moments at the end of formal PMR practice and to incorporate the use of this technique into their daily relaxation applications. Guided imagery can also be introduced by selecting scenes which are associated with tranquillity and pleasantness. Scenes can be constructed such that they sequentially produce deeper states of relaxation and varying types of additional positive affect. Although guided imagery is not useful for the rapid elicitation of a relaxation response during early cue detection, it is a helpful device for deepening relaxation during formal practice sessions or at other moments in the day when a relaxation break is taken in order to reduce built-up anxiety and tension. Many GAD clients are perfectionistic, with high performance standards for themselves and fear of the judgments of others. Consequently, attempting to achieve a completely relaxed state may, in itself, generate anxiety which may interfere with that very goal. The therapist can describe relaxation training in terms of ªmovement toward relaxation.º Applied relaxation is merely a matter of shifting the direction of the internal process away from a spiral of tension and anxiety; the movement toward relaxation process, no matter how slight, is one of the most useful directions because of its direct incompatibility with anxiety. Frequency of application is more important than depth of relaxation. Other than movement toward relaxation, there is no end-state being sought either during training and practice or in application. Perfectionism is only one example of a basis for relaxation-induced anxiety (RIA), a phenomenon common among diffusely anxious individuals. Other possible reasons include the potentially frightening nature of unfamiliar cognitive or physiological activity elicited by relaxation, fear of losing control, and increased awareness of feelings of anxiety or other emotions (Heide & Borkovec, 1984). If the very method for reducing anxiety is itself anxietyprovoking, the likelihood of a therapeutic effect in its application is minimal. Indeed, in the three published GAD therapy investigations which measured the occurrence of RIA during training, the degree of its occurrence negatively predicted outcome (Borkovec & Costello, 1993; Borkovec & Mathews, 1988; Borkovec et al., 1987). Fortunately, methods exist for circum-

venting this problem. Stressing the notion of movement toward relaxation is one. Another is to teach an alternate relaxation technique; clients who experience RIA with one type of relaxation tend not experience it with another (Heide & Borkovec, 1983). Moreover, when the emphasis is on frequent applications of brief relaxation responses to detected anxiety cues rather than on twice-a-day formal practice of deep relaxation, there is less likelihood that clients will experience RIA. Finally, treatment of RIA in more difficult cases is analogous to exposure treatment of any feared event: training can be systematically conducted in a graduated fashion, with exposures to increasingly deeper levels of relaxation over sessions. In our current therapy trial using these methods, the correlation between in-session RIA and therapeutic improvement is no longer significant. One of the overarching goals of relaxation training and application with GAD clients is to increase the amount of time spent focusing on the present moment rather than on anxietyprovoking thoughts and images about the future or the past. Early sessions devoted to the identification of internal triggers to the anxiety spiral have already demonstrated to clients that what they are thinking and imagining contributes significantly to their anxiety; they are partly creating their realities. The next step is to discuss the fact that, when we are thinking about the future or the past, we are creating an illusion. These future and past events do not exist now. But we still react emotionally as if they are actually occurring. Images are particularly powerful elicitors of this effect; they can cause nearly the same degree of physiological reactivity which the occurrence of the real events they reflect would cause. So we produce much of our anxious experience merely by thinking worrisome thoughts and imagining catastrophic scenes. A second disadvantage exists when clients pay excessive attention to the future or the past. As long as they are not paying attention to the immediate environment, they are not processing further information from the actual world; there can be little learning and development in their knowledge and adaptive behavior. The therapeutic implications of this are clear: the more time clients spend focused on what is real and in front of them, the less time they spend creating negative emotional experience and the more time they spend processing adaptive information. Consequently, the therapist works with clients during sessions to practice focusing attention on what is actually present. Initially, with eyes closed, clients are asked merely to attend to sounds occurring in the environment, the tactile feelings of the chair, and the odors in the air. They are

Clinical Description of Cognitive-behavioral Therapy for GAD instructed to return their attention to these sensations whenever they notice their attention drifting to other thoughts or images and to sense them without making judgments or elaborating on their further meaning or associations (i.e., no reactions to reactions). The same exercise is then repeated with eyes open, and later as they walk around the office. They are finally encouraged to increasingly practice shifting to this kind of focus throughout the day and to let the therapist know in the next session what new sensations they have discovered across multiple situations. As clients report that relaxation applications are beginning to have some noticeable effects, they are further encouraged to begin noticing what emerges from states of greater tranquillity. We know from decades of research that anxiety interferes with many adaptive processes and that relaxation facilitates many forms of performance. The inverted-U nature of arousal effects on performance can be described to clients (i.e., anxiety at moderate levels is optimal but can interfere with performance at very low and high levels), and they are asked to begin observing what adaptive behaviors become disinhibited or facilitated when they are creating greater states of relaxation for themselves. These may include more effective interpersonal behaviors, greater clarity or logic in thought, or better efficiency and productivity in work. They are thus invited to explore and discover on their own what benefits relaxation may yield. Behavioral experiments are often useful devices for demonstrating such effects. For example, clients can conduct an ABAB experiment at work, where ªAº represents their usual state during work and ªBº represents work done in a more relaxed state. Emotional state as well as productivity, accuracy, or efficiency can be dependent measures for them to assess the impact of relaxation on their work. 6.19.6.4 Applied Relaxation Merely training clients in a relaxation technique and asking them to practice it twice a day are unlikely to yield significant benefits. It is surprising that before the mid-1980s, many therapy trials which included relaxation methods provided only these elements. Twice-a-day formal practicing is designed to provide momentary breaks to return oneself to a more tranquil state and to further build the skill of eliciting relaxation responses and of identifying what relaxation feels like so that the clients know what it is that they can usefully move toward. But the real potency of relaxation resides in its deployment on a moment-tomoment basis whenever incipient anxiety spirals

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are detected. Although clinical applications of relaxation had certainly been grounded more thoroughly in the importance of daily applications, it was not until OÈst's article on applied relaxation (AR) that clinically thorough relaxation training was incorporated into therapy research (OÈst, 1987). Evidence has now accrued to indicate that this technique by itself can be a potent coping strategy for several anxiety disorders. The essential feature of AR is the frequent elicitation of relaxation in response to anxiety and tension triggers. With GAD clients, this would include worrying. The therapist has already laid the essential foundation of AR in first-session work with clients on early cue detection and the use of diaphragmatic breathing as a rapid coping response to detected cues. Rehearsals of AR take place in the session whenever the therapist suggests a brief application of relaxation in response to observed signs of increased anxiety. Differential relaxation training is also conducted to facilitate the generalization of relaxation skills to daily living. Clients are taught to relax themselves not merely when reclining in a comfortable chair but even when sitting in upright chairs, walking, and engaging in various common activities. The therapist tells clients that unneeded muscular tension comes in two forms: excessive tension in muscle groups required for an activity (e.g., neck muscles needed for holding the head erect) and any tension in muscles that are unnecessary for an activity. The goal of differential relaxation is to identify when either excessive or unnecessary tension exists and to let go of that tension while continuing to carry out the activity. In-session practice involves engaging in commonly performed activities while identifying and relaxing away excessive tension, and between-session practice is encouraged to adopt a more habitually relaxed lifestyle. Cue-controlled relaxation is often instituted wherein a particular word (e.g., ªrelax,º ªcalm,º or a word taken from meditational focusing devices) is paired with the release of muscle tension during PMR and then used as an initial response to initiate applied relaxation in daily coping. Clients can also be encouraged to use the relaxation response as a method of opening up to experience. From a more tranquil center established via relaxation, they are asked to shift their attention more completely and frequently to the world around them, taking in the information which it provides and allowing stressful stimuli merely to ªpass throughº them without reacting to such events. Finally, clients are told that when stressful events are upcoming, they can think in terms of three phases during which they can apply their

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relaxation coping responses: in anticipation of the event, during the event, and in recovery after the event. It is of course useful to deploy their coping strategies throughout these phases. But often, especially in the early stages of therapy, the most noticeable effect of relaxation applications occurs during recovery. It is helpful for clients to realize that more quickly recovering from an anxious experience is a desirable event for increasing their sense of self-control and as a starting point for more effectively reducing anxiety earlier and earlier in its sequence. As skill in applying relaxation to daily events increases, the therapist and clients can begin to create behavioral homework assignments that gradually increase their exposure to stressful, anxiety-provoking situations in which to apply the methods during these three phases. 6.19.6.5 Self-control Desensitization Because worrying prevents emotional processing and imagery can be an effective method for engaging such processing, imagery exposure techniques could be very useful in the treatment of GAD. The problem is that we do not yet know what the core fears of GAD clients are. They are anxious about many situations, therefore either in vivo or imagery exposure to relevant fear-evoking stimuli would be a daunting, potentially excessive therapeutic task. Until the central fears and the images that effectively access those fears can be identified by future research, self-control desensitization (SCD) is a helpful intervention tool. SCD was originally designed to deal with more diffuse anxiety problems for which discrete, graduated hierarchies of circumscribed phobic stimuli were not possible (Goldfried, 1971). In SCD, clients first focus on relaxation process until they have achieved a relaxed state. Next, the therapist asks the clients to imagine themselves in a situation where internal and/or external anxiety cues occur. Clients signal as soon as actual anxious experience is elicited by the imagery, and the therapist then has them imagine coping effectively with the imagined situation by using the relaxation response. Clients signal again as soon as they no longer notice anxious responding, and they continue to imagine themselves in the original situation but effectively coping with it. Finally, images are terminated altogether, and clients return to focusing only on the relaxation process. The goal of SCD is to have the client rehearse relaxation applications to the kinds of situations that they often find problematic. Some degree of extinction process may take place, but the usefulness of the method probably resides more in the strengthening of adaptive

coping responses to typical fear cues. Thus, clients are more likely to remember to employ coping responses during daily living given associative priming effects from previous imaginal rehearsals in therapy. ªHierarchyº construction for SCD is less detailed than it is in systematic desensitization. The therapist helps clients identify both the internal cues of their anxiety spirals (somatic, cognitive (especially worry and catastrophic images), and behavioral) and representative types of external situations where anxiety and worry often occur. Images that include both internal and external cues are constructed for use during SCD and only roughly graded from mild to moderate to severe in anxiety-provoking value. The paragraph below exemplifies one possible method for conducting a formal SCD procedure with such images once the client is in a deeply relaxed state. It includes both therapist patter and procedural instructions. I will now begin to present the images which we discussed earlier. Remember to visualize yourself as if you are actually in the situation as realistically as you can. Also, be sure to raise your index finger immediately when you first notice the beginnings of any tension, anxiety, or shift away from the feelings of deep relaxation. Once you have signaled, be sure to become fully aware of what the feelings are like, continue to imagine the scene that I am describing, and hold your finger raised until you notice that the anxiety feelings are disappearing . . . Visualize yourself at work at your desk with the boss nearby . . . Imagine that your mind is thinking, ªwhat if I make a mistake?º . . . What if I should do something foolish? . . . You can feel the anxiety beginning to increase as your mind is thinking these things . . . The tension and anxiety are rising as your mind continues to worry about acting foolishly . . . Imagine that your heart is beginning to pound . . . More and more quickly and intensely . . .

When the client signals anxiety, or after 60 seconds of visualization without a signal, introduce the coping statements: Just continue to imagine yourself at work at your desk with the boss nearby but now imagine yourself relaxing . . . Just visualize yourself relaxing away the tension and anxiety, letting go of the worries . . . and as you do, imagine that the relaxation is reducing the speed of your heart, the tension in your muscles . . . Calm and peaceful . . . quiet and relaxed . . . Muscles becoming more and more deeply and more completely relaxed . . . Heartracing just melting away, dissipating . . . Breathing becoming more and more smooth and regular . . . As you imagine yourself at work with the boss nearby and relaxing more and more . . . Just letting go of the tension and anxiety and worrisome thoughts and focusing on your work . . .

Clinical Description of Cognitive-behavioral Therapy for GAD Continue such patter for another 20 seconds if there is no client signal, then terminate the image and use periodic relaxation patter to deepen the relaxed state for 20 seconds. If there is a client signal, continue with the above patter (eliminating references to the anxiety cues) for another 20 seconds beyond the point where the anxiety signal is dropped: Just continue imagining yourself at work with the boss nearby . . . Relaxing more and more deeply . . . Muscles continuing to smooth out and unwind . . . Loosening up and becoming more and more comfortably and deeply relaxed . . . Nothing to do but to enjoy the pleasant sensations of relaxation as the relaxation process continues to take place as you imagine yourself peacefully at the office focusing on your work.

Then instruct the client to stop visualizing that scene and to continue focusing on the relaxation for another 20 seconds: Stop visualizing that scene and go on relaxing . . . Allowing the relaxation process to continue to take place now . . . Calm and quiet . . . Peaceful and relaxed . . . Simply enjoy the pleasant feelings of relaxation and notice how very good it feels to be so deeply and completely relaxed.

Repeat each image a minimum of three times, or, if anxiety was signaled, until the client twice consecutively no longer signals anxiety within 60 seconds or until the client is able to terminate the anxiety fairly quickly (e.g., drops signal within seven seconds). Over time, the therapist introduces more anxiety cues into the images. Ultimately, the client should be able to imagine all cues typical of their anxiety experience, either without reacting with anxiety or being able to rapidly terminate the anxiety. Varied environmental contexts which incorporate the client's typical anxiety-provoking situations can be used in the imagery scenes. Not every cue will have a chance to be paired with every environmental context. It is ideal to avoid over-repetition of any one context and to cover a representative sampling of contexts and at the same time provide a complete coverage of the kinds of internal anxiety cues typically experienced by the client. Once formal SCD has been initiated in therapy, clients are asked to use the technique at the end of their own daily relaxation practice sessions. The client begins by repeatedly employing the same image that was introduced in the last therapy session. This image should be used until it no longer elicits anxiety, at which time another image that represents the kinds of anxious experience that they have during the week can be substituted.

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As therapy progresses, the therapist can also employ an informal variant of SCD: whenever clients begin discussing upcoming stressful events or current worries, the therapist can, with or without first eliciting a relaxation response, ask them to close their eyes and engage in an SCD presentation involving these situations or worries. For worries in particular, the therapist can merely ask the client to begin worrying, and, once it is established, to let it go and relax. Finally, toward the end of therapy, formal SCD can be done in two additional ways that mimic real life events to a closer degree. One involves sequentially presenting several different images representing a variety of different stressful events or circumstances without the client planning these images beforehand and with only a single presentation of each image. Thus, an element of surprise typical of naturally occurring events can be incorporated into imaginal rehearsals. The other method is to present unplanned images that form a seamless story that is both typical of the client's daily experiences with anxiety and represents a building accumulation of stressful events. During both methods, the client's task is merely to engage in ongoing coping in the usual imaginal way as previously done, but without breaks in the scene presentations. Once CT (discussed below) has been initiated, self-statements that are anxiety-reducing for a particular client can be added to their repertoire of coping responses during SCD imaginal exposures. Thus, the client is encouraged to use both relaxation responses and perspective shifts to more accurate ways of thinking about the represented situation as means of coping with the anxiety and worry elicited by the scenes. 6.19.6.6 Cognitive Therapy Basic CT for anxiety disorders (Beck & Emery, 1985) involves a fairly straightforward series of steps which can be summarized by a set of questions that the therapist can ask the client: (i) How are you perceiving the situation (what are you thinking, imagining, predicting, saying to yourself, interpreting, believing)? (ii) Is this way of perceiving accurate (what is the evidence)? (iii) If this way may not be true, what alternative ways are there to see the situation that have evidence for being more or equally accurate? (iv) Whenever you notice yourself using the old way, why not try viewing the situation with one of the alternatives which may be more true, or try testing out the perspectives by conducting

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experiments during your daily life to get the evidence you need? In initial sessions, the therapist already helped clients identify the variety of internal cues associated with their anxiety and worry, including thoughts and images, to notice what immediate effect these cognitions can have, and to notice that their minds and bodies are reacting to something that is not now present and does not exist in the present. Clients are encouraged to view cognitive events as hypotheses rather than as facts, as predictions which may come true in the future. They are asked to estimate the probability that their feared outcome will actually happen. This question is linked to the idea that it is wise for them to avoid only probable dangers rather than every conceivable outcome. If the danger does not have a high likelihood of occurrence, there may be more accurate predictions available. If the danger does have a high likelihood, the client is asked to rate how well he or she could cope with the feared outcome. This question is linked with the idea that we often underestimate our ability to cope with predicted negative events. When analyzing the truth-value of particular perspectives, clients are asked to consider the advantages and disadvantages of this way of seeing things and to examine the evidence for it. Quite often, very few advantages can be identified, and the anxiety and worry that follow from it are obvious to the client. The probability of something happening in the future is often best estimated by how frequently it has happened in the past, and the therapist and client can search personal history to come up with a meaningful estimate of the chances for the occurrence of the feared event. In addition, statistics are sometimes available to specify the likelihood of some negative events. Although such traditional methods of helping clients logically analyze the likelihood that their perspectives are accurate or inaccurate are useful, the most important therapeutic task involves learning to observe the environment on a daily basis, fully processing the new information that is available, and using this information to construct new models of the way things actually are. GAD clients have two characteristic tendencies which ordinarily counteract such a process: focusing on mental illusions of the past and the future and excessively attending to the negative features of environmental information. Therapists therefore encourage them to become more objective in their view of events, distinguishing what is actually and descriptively occurring from their interpretations of events or their guesses about what the events may mean. One of the best ways of helping them with these tendencies with regard

to their worrying involves daily monitoring of worry content and the specific predictions they are making and then observing the actual outcomes which eventually occur. As mentioned earlier, when an outcome relevant to a worry does occur, they rate how bad the outcome was and how well they coped with it. They are asked to think carefully about each actual outcome and what it might mean for revising their models of the way things are. By using the worry outcome monitoring method, clients create their own new history of events, more objectively considered, upon which to base predictions about the future and ways of seeing themselves in the world. Because so many anxieties and worries relate to social evaluative situations, distancing methods are often initially useful, wherein clients are asked to logically analyze the thoughts and predictions of another person rather than of themselves (e.g., a friend or acquaintance, a hypothetical stranger, or the therapist roleplaying someone else). Such distancing reduces the likelihood of the clients' habitual fear and avoidance responses to such material and allows them to think more clearly and to reason more accurately. As clients engage in logical analysis and generate more accurate perspectives, they commonly report that the alternative perspective just does not feel true in the way which the old view does, even though it is more logical. There is very good reason for this. Worry contains numerous brief images of negative events, and imagery can result in bodily reactions similar in type and intensity to the actual occurrence of an event. The more one imagines catastrophes, the more real they feel. Of course images of more likely positive outcomes have been occurring far less frequently, so the ªfeelingº that these are true is less strong. This is one of the reasons why the cognitive products from CT are incorporated into SCD procedure and why realistic images that indicate everything turning out well can be usefully added toward the end of coping image rehearsals. Although CT begins with specific thoughts and images, the therapist and client eventually identify recurrent, underlying themes that reflect their core beliefs and CT proceeds in a similar fashion using the core beliefs as targets for intervention. Formal assessment of characteristic thought styles can facilitate the identification of such schemata. Among the factors from the Dysfunctional Attitude Scale (Beck, Brown, Steer, & Weissman, 1991), GAD clients in the current Pennsylvania State Project score highest on items referring to fear of disapproval, dependence on others for their

Clinical Description of Cognitive-behavioral Therapy for GAD happiness, and excessively rigid rules about the way things ªshouldº be. A major goal for CT with GAD, therefore, involves the creation of greater freedom from others' opinions and more flexible rules by which to judge oneself and others. Central to these is the gradual shifting of perspective from an extrinsic to an intrinsic focus. If clients can learn to attend only to the process of their actions and experiences rather than to the outcomes, less time will be spent generating anxiety-provoking cognitions about what negative things might happen, and more time is devoted to attending to the form and quality of the process of living. For example, when people are at work, they can choose to pay attention to the external rewards which may come from the work (and thus create performance anxiety due to fear of failure), or they can choose to focus on the work itself, its intrinsic meaning, or how it can be done in a beautiful, skillful, or joyful manner. Therapists can help clients to identify the specific elements of any activity or role which can be pleasing or lifeaffirming. Rehearsals in SCD of adopting such alternative perspectives can strengthen the tendency to employ such views on a daily basis. Clients can have a difficult time at the beginning of CT when they are asked to generate alternative ways of thinking or believing; old habits have often been present for a long time. To facilitate flexible thinking, it is useful first to practice generating multiple perspectives on neutral topics where avoidant tendencies are less strong. For example, how many ways are there to see this pencil? What shapes can we see in the cloud formations? How many different ways do characters in situation comedies on television view the same ªobjectiveº event? Such rehearsals of flexible thinking show clients that many ways exist to perceive something and that we can create what those ways are for any situation. When the therapist eventually addresses anxiety-provoking situations, the first step is to generate several possible perspectives (even humorous ones) without initially judging their reasonableness. The second step is to choose one of the perspectives for application, using such touchstones as evaluating the advantages and disadvantages of each perspective and judging its likely accuracy based on logic, probability, and evidence. In defining their core beliefs, GAD clients also often use words which have a strong emotional impact and which are vague enough to apply to any situation. For example, a common core belief for someone with GAD might be, ªI must be perfect at everything I do or I am a failure.º A helpful intervention is to ask the client to define what they mean by each word in the above phrase and to determine how

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realistic it is. For example, how do they determine their own perfection? Do they really need to do everything perfectly, or are there only some things which are important? Is it possible for them to be perfect at everything? Could they still be successful at something if it was not perfect? The therapist can encourage clients to reword their core beliefs so that they are much more specific. For example, instead of using the above phrase, the client might state, ªI choose to be the best (mother, teacher, writer) that I can.º The latter phrase is much more specific, avoids social comparison by refocusing on self-competition, focuses on the process (trying one's best) instead of the outcome, and implies choice. A goal of CT for GAD involves the creation of more balanced perspectives, that is, the addition of realistic views to older, habitual, negative views. It is not a matter of looking at the world with rose-colored as opposed to brown glasses, but rather of using clear glasses. With a greater number of perspectives available, clients have choices rather than being determined by habit. Once more adaptive cognitions are employed with success in their daily lives, clients can be introduced to one further step: expectancy-free living. Although planning and anticipation are necessary human processes under certain circumstances, much of the time expectancies are not necessary. In fact, expectancy can distort the processing of information, influence what is recalled from memory, create negative mood states during anticipatory periods if its content involves negative predictions, and can never fully anticipate the way things will turn out anyway. Living with a focus on the present, processing information from the world as it arrives, and trusting one's ability to cope with whatever comes down the road are alternative perspectives potentially useful to practice to help the client discover under what circumstances such a lifestyle can be adaptive and enjoyable. As an anonymous poet from Crete wrote, ªI fear nothing; I hope for nothing; I am free.º Because so much of the inner life of the GAD client revolves around fear of potential bad things which might happen, a perspective shift which defines ªbadº in a more relativistic way can be helpful. Certainly we need to evaluate and react to events as they occur partly on the basis of our immediate judgments about ªgoodº and ªbad.º But events reflect only relative and not absolute qualities. For example, the first author as a teenager spent his life savings on a used car, whose engine died two months later. This was a bad thing. However, it forced him to find a new job reachable by public transportation. The new job location was where he met his wife, the best thing that has ever happened to

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him. We cannot adaptively seek out bad events just because they might lead to something good. But when either bad or good events happen, it is useful to realize that new choices are made available, new doors are opened, and nothing is absolutely bad. If this is the case, then anticipations of bad events, so frequently characteristic of GAD, take on a slightly less rigid meaning. Decatastrophizing is a useful, traditional CBT method with GAD. Given that clients frequently fear the worst, identifying what exactly that would be, the various steps which it would take to get to that point, the probability of each step, what alternative perspectives could be adopted, and what coping resources exist for each step can often significantly reduce the fear associated with the area of concern. If the probability of all steps occurring together is established to be quite low and the likelihood of inability to cope is determined to be nearly nonexistent, clients can be encouraged to consider a horse-betting analogy. Would they bet their life savings on a horse which has come in last every time in the past or on a horse which has always won? They may wish to consider how they are betting their daily emotional life in a similar context. Behavioral experiments can be constructed for clients to conduct between sessions to test old and alternative perspectives. Such experiments often provide opportunities for graduated exposure as well. Asking clients to approach feared situations to obtain evidence for beliefs can thus serve a dual purpose. Although circumscribed anxiety-provoking situations are not as salient in GAD, clients do often engage in a variety of subtle avoidances (Butler, Cullington, Hibbert, Klimes, & Gelder, 1987). One frequent area of avoidance inherent to GAD is cognitive avoidance. For true exposure to be enacted, cognition and behavior must both reflect an approach. What perspective clients adopt during an approach behavior can make a difference to the extinction process. Fear of bees is an instructive example. Fearful people often swat at bees flying around them, an irrational, nonapproach act that increases rather than decreases the likelihood of being stung. Eliminating the swatting and sitting motionless until the bee flies away still includes avoidant behavior (a freezing response). Opening up one's palm to the bee in an invitation to land on the hand is an example of a true approach response in both cognition and behavior and is likely to facilitate extinction and changes in threatening meaning. GAD clients are excellent ªyes, but . . .º debaters. They have rich associative networks which construct an elaborate view of why the world is a dangerous place and why they may

not be able to cope. Although CT can be seen as a very systematic, step-by-step system for modifying cognitions, there is no need to follow those steps in textbook fashion. Indeed, overly rigid therapist pursuits can lead to arguments, frustration on the part of both therapist and client, and ruptures in the therapeutic alliance which make therapy less likely to be beneficial (Safran & Segal, 1990). The alternative is to reduce the pressure on both parties, deemphasizing the need to reach a specific outcome in any particular session. The real goal is the creation of a process designed to loosen up the client's rigid, habitual modes of thinking and to generate more flexible thinking in a gradual fashion. There are many specific techniques in CBT, and the therapist can often move smoothly among topics and techniques from moment to moment in the session. As therapists do so, they watch for a softening of the client's reactions to any one of these and pursue any openings which emerge more deeply until signs of avoidance or resistance are encountered. Such an approach keeps the therapeutic process flowing without significant obstacles and no sense of failure. 6.19.7 SUMMARY AND IMPLICATIONS FOR FUTURE THERAPY DEVELOPMENT Basic research has revealed several interrelated features for GAD which fall into three major domains: GAD (i) involves a process (worry) which functions as cognitive avoidance to anxiety-provoking material, prevents emotional processing, and thus contributes to the maintenance of anxious meanings; (ii) has a distinctive physiology typified by autonomic inflexibility and deficiency in parasympathetic tone; and (iii) is associated with specific current interpersonal problems which may have developed partly on the basis of insecure childhood attachment. Outcome findings suggest that combined CBT is likely to be the most effective intrapersonal treatment approach for producing long-lasting change, but absolute degree of improvement remains unsatisfactory. It seems likely that something else must be added to ªbest availableº CBT techniques to yield greater and maintained clinical improvement. Prior theorizing about GAD has emphasized the role of habitual, nonlinear, dynamical interaction of multiple intrapersonal processes (attention, thought, imagery, affect, physiology) over time in response to constantly perceived threat. The superiority of combined CBT relative to its elements does suggest that the therapeutic targeting of all relevant systems will yield the greatest change. However, attachment and

References interpersonal problem results now suggest an extension of this model to include another relevant system, that is, the habitual cycles of interpersonal behavior which may also contribute to maintenance of the maladaptive anxiety process. Perceived threats are often significantly related to interpersonal situations (e.g., fears of criticism for socially avoidant clients, fears of being attacked or controlled by others for dominant-hostile clients, fears of failure to take care of others and so to obtain love and approval for overly nurturant clients). The interpersonal behaviors learned to cope with these fears can be readily seen in a functional sense as negatively reinforced avoidance of such feared interpersonal consequences and of the developmentally based anxieties which underlie those interpersonal fears. Taken together, results and theory extension provide a rich context for understanding the nature, functions, maintenance, and origins of GAD and thereby for guiding the development of more effective treatment. They suggest that future research and therapy development would benefit from a focus on (i) identification of the specific nature of the core fears in GAD and the development of more powerful methods for the emotional processing of those fears, (ii) the creation of more impactful relaxation methods for increasing parasympathetic tone, and (iii) the pursuit of the functional role of interpersonal problems in GAD process and how best to modify these problems. ACKNOWLEDGMENT This research was supported in part by National Institute of Mental Health Research Grant MH-39172 to T.D.B. 6.19.8 REFERENCES Abel, J. L., & Borkovec, T. D. (1995). Generalizability of DSM-III-R generalized anxiety disorders to proposed DSM-IV criteria and cross-validation of proposed changes. Journal of Anxiety Disorders, 9, 303±315. Alden, L. E., Wiggins, J. S., & Pincus, A. L. (1990). Construction of circumplex scales for the Inventory of Interpersonal Problems. Journal of Personality Assessment, 55, 521±536. Andrews, V. H., & Borkovec, T. D. (1988). The differential effects of induction of worry, somatic anxiety, and depression on emotional experience. Journal of Behavior Therapy and Experimental Psychiatry, 19, 21±26. American Psychiatric Association (1980). Diagnostic and statistical manual (3rd ed.). Washington, DC: American Psychiatric Association. American Psychiatric Association (1987). Diagnostic and statistical manual (3rd ed. Rev.). Washington, DC: American Psychiatric Association. American Psychiatric Association. (1994). Diagnostic and statistical manual (4th ed.) Washington, DC: American Psychiatric Association.

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