Psychiatric Annals

CME Article 

Psychotherapy for Generalized Anxiety Disorder

Jürgen Hoyer, PhD; Colin van der Heiden, PhD; Michael E. Portman, DPhil, LISW-S


Generalized anxiety disorder (GAD) is increasingly recognized as a prevalent anxiety disorder with a chronic course and significant impairment.1 Chronic and uncontrollable worry, a future-oriented and highly negative form of verbal thought, is considered its key feature. However, GAD is also associated with rigidity and dysfunctions in cognition, affect, and behavior, as well as physiology.2 Negative and self-perpetuating spiralling interactions between these domains are thought to comprise GAD.


Generalized anxiety disorder (GAD) is increasingly recognized as a prevalent anxiety disorder with a chronic course and significant impairment.1 Chronic and uncontrollable worry, a future-oriented and highly negative form of verbal thought, is considered its key feature. However, GAD is also associated with rigidity and dysfunctions in cognition, affect, and behavior, as well as physiology.2 Negative and self-perpetuating spiralling interactions between these domains are thought to comprise GAD.

Jürgen Hoyer, PhD, is with the Department of Clinical Psychology and Psychotherapy, Technische Universität Dresden (Germany). Colin van der Heiden, PhD, is with the Outpatient Treatment Centre PsyQ, Rotterdam, The Netherlands. Michael E. Portman, DPhil, LISW-S, is with the Cleveland Veterans Administration, Case Western Reserve University, Cleveland, OH.

Dr. Hoyer and Dr. van der Heiden have disclosed no relevant financial relationships. Dr. Portman has disclosed the following relevant financial relationships: Springer Science: Royalty recipient.

Address correspondence to: Jürgen Hoyer, PhD, Technische Universität Dresden, Klinische Psychologie und Psychotherapie, Hohe Str. 53, D-01187 Dresden, Germany; fax 49-351-46336955; or e-mail:

Generalized anxiety disorder (GAD) is increasingly recognized as a prevalent anxiety disorder with a chronic course and significant impairment.1 Chronic and uncontrollable worry, a future-oriented and highly negative form of verbal thought, is considered its key feature. However, GAD is also associated with rigidity and dysfunctions in cognition, affect, and behavior, as well as physiology.2 Negative and self-perpetuating spiralling interactions between these domains are thought to comprise GAD.

For instance, worry may lead to anxiety symptoms (eg, racing heart), resulting in an elevation in worrisome thoughts (eg, “If I can’t stop worrying, maybe I will have a heart attack?”) and anxiety, which patients may attempt to control by using counterproductive mental regulation (eg, thought suppression) and avoidance strategies (eg, reassurance seeking).

Cognitive-behavioral therapy (CBT) has been found to be an efficacious approach in the treatment of GAD as compared with wait-list or treatment-as-usual control groups.3 As such, CBT is currently considered the psychological treatment of choice for GAD. Although there is not one CBT approach, the basic tenet of most approaches is that cognitive processes mediate patterns of thinking, behaving, and feeling that underlie GAD. In this psychotherapeutic approach the patient and therapist work together to alter distortions in thinking and to learn adaptive coping strategies to replace avoidant ones (such as worrying), with the aim to improve the ability to think more rationally, act in a more adaptive manner, and relieve emotional distress.

Most of the therapeutic work is done outside of the therapy sessions, in the form of homework assignments pertaining to technique rehearsal and application in “real life.” Although specific interventions follow from particular models of GAD, most CBT packages share several “essential” components, which are listed in Sidebar 1.

Sidebar 1.

PsychoeducationSelf-monitoringStimulus control techniquesRelaxationSelf-control desensitizationCognitive restructuringWorry exposureWorry behavior modificationProblem-solving

The purpose of this article is to describe these common, essential components of the CBT approach to the treatment of GAD. In addition, some innovative GAD-specific treatment packages will be introduced. These new treatments have been developed to augment the efficacy of CBT for GAD, as reviews of the clinical significance have indicated that only about 50% of patients with GAD return to a “well” status (ie, falling within normal limits on outcome measures) following treatment.3,4

Components of CBT for GAD


Psychoeducation is the first step in the treatment of GAD and involves providing information about the disorder and its treatment. It is explained to patients that over time, worry and anxiety have become excessive and uncontrollable, are accompanied by physical symptoms, and interfere with daily functioning and quality of life. The CBT conceptualization is presented, in which the relationships between thoughts (worries), behaviors, and feelings are explained. Finally, information on the treatment is provided, including the components of treatment, duration, frequency of sessions, and the role of patients and therapist (“collaborative empiricism”).

Psychoeducation may serve several goals:

  • Relief (“I am not the only one”);
  • Destigmatization (“Worry is not abnormal, but an extension of a normal phenomenon”);
  • Enhancing motivation for treatment by providing a rationale for the components of treatment (“There is an effective treatment for my problems”); and
  • Increasing compliance by developing realistic expectations about treatment (“So I will have to do homework in order to learn to cope with my worries”).


Self-monitoring typically involves daily diaries in which patients note the times and places of worry episodes, the events that triggered the worrying, the level of anxiety, including symptoms that were present, and the topics they worried about.

As such, patients learn to recognize how cues and worry states interact early in the sequence, as a result of which they will later be able to apply new, more adaptive coping strategies as soon as worry episodes begin.2,5 Apart from being an assessment procedure, the monitoring process itself often reduces anxiety.6

Stimulus Control Interventions

Stimulus control interventions are based on the idea that the various contexts in which patients with GAD have learned to worry have become worry triggers in their own right. As worry (viewed as an internal, voluntary, operant behavior) can occur at any time and in any place, worrying is likely to become associated with an increasing number of contexts (internal and external stimuli).

In order to achieve greater stimulus control of, and thus reduction in, worry, deliberately limiting the stimulus conditions under which worrying occurs is a helpful method.5 This can be achieved by scheduling worry time, in order to diminish associations between anxiety-provoking contexts and worry. Patients are instructed to postpone worry during the day to an established daily half-hour worry period in a selected worry location that will be devoted exclusively to worry and problem-solving.

Relaxation Techniques

Relaxation techniques are designed to reduce somatic tension and increase autonomic flexibility by lowering overall arousal level and widening the scope of attention, thereby increasing the ability to consider alternatives in feared situations and serving as a distraction from persevering thoughts. There is a range of relaxation techniques, including deep breathing exercises, progressive muscle relaxation, and applied relaxation. Presenting a number of these strategies allows patients to select those that they prefer.

First, deep breathing exercises can help to shift the breathing away from the chest to breathing from the diaphragm. This slower paced, more relaxed form of breathing has been found to stimulate the relaxation response of the parasympathetic nervous system.2 Patients learn to breathe slowly, rhythmically, and regularly from the diaphragm region, first by therapist modeling and in-session exercises, and then by practicing deep breathing daily as a homework assignment.

Progressive muscle relaxation can serve to create a physiologic response antagonistic to anxiety, which may be used as a means of letting go of physical tension.7 In this technique, patients are taught to systematically tense and then relax 16 major muscle groups. By first focusing attention on and tensing each muscle group for several seconds, a stronger relaxation response is allowed for when instructed to relax and focus on the sensations of warmth and relaxation in the targeted muscle group. Over time, muscle groups are combined to make the technique more efficient, and later on, patients learn to create relaxation by merely recalling the sensations associated with the relaxation response (“relaxation by recall”).

A final relaxation technique is called applied relaxation,8 after which patients gradually learn to apply relaxation skills when detecting shifts in anxiety levels in real-life situations. This is accomplished by successively learning to achieve relaxation in response to a self-produced cue (eg, a word or number) previously paired with relaxation responses, practicing muscle relaxation without tensing them first, and applying relaxation skills in everyday situations and stressful events.8

Applied relaxation has received empirical support as a stand-alone treatment for GAD, without combining it with other CBT techniques.9,10 Applied relaxation has also been found to be effective for all GAD symptoms (worry, anxiety, somatic tension) without directly targeting worrying as its primary goal.

Self-Control Desensitization

Self-control desensitization is a technique in which patients employ imaginal rehearsals of developing coping responses in the context of induced anxiety.11 After patients are deeply relaxed using relaxation techniques, they vividly imagine themselves in situations that commonly trigger anxiety and worry until they experience actual internal anxiety cues. Patients then imagine themselves successfully coping with the situation in order to decrease the anxious responses, and, if anxiety has diminished, they turn off the scene and deepen their relaxed state.

Cognitive Restructuring

Cognitive restructuring is employed because GAD involves maladaptive cognitive processes, such as the pervasive perception of threat, frequent predictions of catastrophes, and self-strengthening worry. The role of “cognitive distortions,” particularly the tendency to overestimate the likelihood of negative events and to underestimate one’s ability to cope with such events, in maintaining worry and anxiety are reviewed with patients in the Psychoeducation section (see page 88). Cognitive restructuring aims at helping patients to shift from worrisome activity to perceiving the world, the future, and themselves in a more functional and adaptive manner.5

The process of cognitive restructuring involves Socratic questioning and behavioral experiments. Socratic questioning is a nonconfrontational style of questioning to lead patients to think through their worries and anxieties, with the aim to help them come to realize that alternative interpretations and feelings are more accurate (“guided discovery”). Behavioral experiments serve as a means to actually test the validity of the negative and competing alternative thoughts in real-life situations.

Worry Exposure

Worry exposure is an imaginal technique developed as an intervention for the treatment of pathological forms of worry.12 It is based on the notion that worries are mainly abstract and verbal-linguistic in nature, thereby preventing access to emotionally laden images and thoughts that constitute the fear structure.13 This cognitive avoidance is addressed by means of worry exposure exercises, during which patients imaginally expose themselves for a prolonged period (25 to 30 minutes) to images of the most feared outcomes.

Together with this exposure assignment, a response-prevention instruction is given. Patients are told that attempts to neutralise the image (eg, by seeking distraction or by thinking about/doing something else) are not allowed. After exposure to the most feared image, patients are asked to generate alternative outcomes of the feared image. The goal of this intervention is twofold: habituation to the feared image and the accompanying arousal and changing the meaning of the feared situation.

Worry Behavior Prevention

Many patients with GAD use unhelpful behaviors to deal with worrying, such as reassurance-seeking, avoiding situations that might trigger worrying, or excessive searching for information. Unfortunately, engagement in such coping strategies might contribute to the persistence of the problem. For instance, patients search for information to discover that there is nothing to worry about but frequently reveal more potential threats that act as triggers for worrying.

Similarly, avoidance of situations that might trigger worrying precludes the experience of discovering that the feared catastrophes do not happen and that patients are able to cope with the situations. Worry behavior prevention involves a procedure similar to that of response prevention used in the treatment of obsessive-compulsive disorder (OCD). Patients first carefully monitor their worry behaviors and are then asked to prevent themselves from engaging in these behaviors and instead to use coping techniques they learned earlier in the treatment.14

Problem Solving

Patients face GAD with two types of worry: worries about situations that are amenable to problem-solving and worries about situations that are not.15 The first type of worry often concerns actual or current problems; the second type is more about potential or hypothetical problems. Whereas the latter type of problems must be dealt with via worry exposure, the likelihood of occurrence of the actual or current problems can be reduced with a problem-solving approach. The process of constructive problem solving includes five steps:16

  1. Problem definition;

  2. Goal formulation;

  3. Generation of alternative solutions;

  4. Decision-making; and

  5. Solution implementation and verification.

In Step 1, the therapist helps patients to stay focused on the problem at hand and to identify the most important elements of the problematic situation. Next, in Step 2, patients are taught to formulate clear and concretely defined goals, which are realistic and attainable.

In steps 3, 4, and 5, patients actually practice problem-solving skills, by first brainstorming about possible solutions for the problem in question and then charting the advantages (or benefits) and the disadvantages (or costs) for every solution, on the basis of which they choose the solution they wish to implement.

Augmentation of CBT for GAD

There is little debate that CBT is an efficacious therapy for GAD. However, CBT for GAD is a good example of the discrepancy between statistically and clinically significant change. Although several studies have shown CBT to lead to statistically significant improvements and large effect sizes,17 only about 50% of treatment completers achieve high end-state functioning3 or recovery4 after treatment. These data show that there is room for improvement and a need for augmentation of current CBT strategies.

It has been suggested that progress might be made by basing treatments on a model of the mechanisms and factors underlying pathological worry, the hallmark of this disorder, instead of using treatment strategies that have been used for many disorders in most studies.18 More precisely, the focus of treatment in traditional CBT has been on challenging and restructuring the content of worry and prevention of worry behavior rather than targeting the basic mechanisms of GAD.

In an attempt to improve the understanding and treatment of GAD, the theoretical conceptualization of GAD has undergone considerable scrutiny and refinement in the past 15 years (see article by Fisher et al., page 127). Contemporary models of this disorder emphasize the avoidance of internal affective experiences, with some of them assuming a special role for aberrant cognitive processes.19 So far, the results of a limited number of studies on the efficacy of treatment programs based on these innovative conceptualizations of GAD have been promising.19

The current article introduces seven innovative treatment strategies for GAD (see Sidebar 2, page 89), including a description of the basic tenets of the model from which each strategy is derived. The first four treatment programs have been described and studied as stand-alone treatments for GAD, the latter three as additional strategies that may enhance the efficacy of CBT for GAD.

Sidebar 2.

Stand-alone Treatments:CBT based on the Intolerance of Uncertainty model (IUT)Metacognitive therapy (MCT)Massed worry exposureAcceptance-based behavior therapy (ABBT)Additional Treatments:Integrative psychotherapyWell-being therapy (WBT)Motivational interviewing (MI)38

Intolerance-of-Uncertainty Therapy

Intolerance-of-uncertainty therapy (IUT) refers to the tendency to react negatively to uncertain and ambiguous events, independent of their probability of occurrence and their associated consequences.15 According to the IUT model, patients with GAD are prone to display chronic worry in response to uncertain and ambiguous situations, based on beliefs that worry will either help them to cope more effectively with such events, or to prevent feared events from happening.

Following the IU model, treatment of GAD should focus on decreasing anxiety and the tendency to worry by helping patients develop the ability to tolerate, cope with, and even accept uncertainty in their everyday lives.

The IUT approach uses typical elements of CBT treatments, such as psychoeducation, worry-awareness training, re-evaluation of the usefulness of worrying, problem-solving training, and imaginal exposure. In the most recent refinement of this treatment,15 a specific component, uncertainty recognition and behavior exposure, was added in which patients learn to recognize uncertainty-inducing situations and manifestations of IUT and to expose themselves to such situations and manifestations.

Several studies support the efficacy of this treatment. Two studies20,21 revealed that IUT was superior to a wait-list control condition on all outcome measures and that treatment gains were maintained over the follow-up periods (up to 24 months). A third study found IUT to be more effective as compared with nondirective therapy in terms of medication discontinuation in long-term benzodiazepine users.22 Results of a recent randomized controlled trial (RCT) comparing IUT, applied relaxation (AR), and wait-list control, confirmed the efficacy of IUT and AR. The findings suggest that although both treatments produce comparable outcomes, only IUT appears to lead to continued improvement in the follow-up period.23

Recently, IUT was compared with metacognitive therapy (MCT) and a delayed treatment control group (DT) in a large RCT.24 At posttreatment and follow-up assessments, MCT and IUT, but not DT, produced significant reductions in GAD-specific and comorbid symptoms, with large effect sizes on all outcome measures. In both treatment conditions the majority of the patients (91% in the MCT group and 80% in the IUT group) were no longer fulfilling the diagnostic criteria for GAD.

However, at posttreatment (but not at follow-up) MCT yielded a significantly better effect than IUT on worry. In addition, MCT achieved higher recovery rates than IUT on measures of worry (posttreatment: MCT 72%, IUT 48%; 6-month follow-up: 74% and 63%) and trait anxiety (posttreatment: MCT 68%, IUT 59%; 6-month follow-up: 72% and 62%).

Metacognitive Therapy

The metacognitive model asserts that beliefs about worrying are central in the development and maintenance of worrying.18 Worry is regarded as an attempt to generate ways of coping for potentially threatening events based on positive beliefs about the usefulness of worry (eg, “I have to worry to stay in control”). As such, the process of worry in itself is not considered to be unique for GAD nor sufficient to cause this anxiety disorder.

Instead, negative beliefs about the uncontrollability and dangerousness of worry (eg, “If I cannot stop my worrying, I will go crazy”) are regarded as crucial for the development of GAD. Such negative metacognitions begin to develop when worrying becomes inflexible and persistent. Once activated, these beliefs about worrying result in meta-worry, in which patients with GAD worry about the fact that they worry. As a result, patients with GAD experience an elevation in anxiety and worrisome thoughts, which ultimately lead to the use of counterproductive mental regulation (eg, thought suppression) and avoidance strategies (eg, reassurance-seeking and keeping away from worrisome situations).

As a consequence, interventions should be aimed at modifying metacognitive beliefs about worrying, instead of modifying the worry itself or teaching ways to control worrying. Metacognitions are challenged by means of verbal cognitive restructuring strategies (eg, questioning the evidence supporting these beliefs and employment of a mismatch strategy in which patients are asked to compare their worrisome predictions with the actual outcome of situations) and worry experiments.

An example is a worry postponement experiment, in which the belief that worry is uncontrollable is tested by asking patients once worry starts to postpone it until a certain point in time. Worry modulation experiments are employed to test positive beliefs about worry by asking patients to decrease worry on one occasion and increase worry on another occasion to determine whether greater worry indeed leads to more positive outcomes.

MCT has been evaluated in an open trial25 and two randomized controlled trials,25,26 all of which achieved favorable results. In the open trial, recovery rates were 87.5% at posttreatment and 75% at 6- and 12-month follow-up on a measure of trait anxiety. MCT was found to be superior to applied relaxation in a preliminary RCT,26 with recovery rates of 80% at posttreatment and 70% at follow-up on measures of worry and trait anxiety (as compared with recovery rates of 10% and 20%, respectively, on both measures in the AR condition). The second RCT compared MCT with IUT and a delayed treatment control group.24

Massed Worry Exposure

Worry exposure has already been described as a component of a generic CBT approach for GAD. Recently, a form of worry exposure has been found to be effective as a stand-alone treatment for GAD (ie, without the additional use of cognitive or relaxation interventions).27 Although so-called massed worry exposure focused solely on worry, this approach proved efficacious for the entirety of GAD symptoms.

In massed worry exposure, the therapist asks the patient to describe an intensely feared situation (eg, “My child will be involved in a car accident”) as accurately and detailed as possible and how he or she would feel and what he or she would think during the situation, what kind of symptoms would occur, and what the person would hear, smell, and taste. Once such a full “worry scenario” has been developed in sufficient detail, patients are motivated to confront this imagery and to try to experience the accompanying anxiety as intensely as possible until habituation occurs.

Acceptance-Based Behavior Therapy

In the acceptance-based model (ABM) of GAD,28 the verbal-linguistic worrying typical of GAD is viewed as a strategy to avoid internal experiences perceived to be negative (eg, thinking of emotional responses as undesirable or feeling fear in reaction to fear). GAD is further characterized by a reduced engagement in meaningful actions and activities. This behavioral restriction develops as patients with GAD become more experientially avoidant of their internal experiences.

As such, the ABM consists of four components:

  1. Internal experiences;

  2. A problematic relationship with these experiences;

  3. Avoidance of internal experiences; and

  4. Behavioral restriction.

The treatment strategy, which is derived from this model of GAD, ABBT, comprises four components:

  • Psychoeducation on the ABM and ABBT;
  • Mindfulness, early cue detection, and monitoring;
  • Mindfulness and acceptance exercises;
  • Behavior change and valued action.28

Some of these procedures are also found in other CBT packages, including early cue detection, self-monitoring, and reduction of avoidance behaviors, but their application within an ABBT context differs on some points from standard CBT. For instance, mindfulness and acceptance exercises in ABBT are focused on promoting a more forgiving nonjudgmental attitude to internal and external experiences and on fully experiencing sensations, however painful and unpleasant, in the present moment instead of trying to reduce and control worry.

Another key difference is that behavior change is not directly aimed at preventing worry behavior but at increasing the consistency between patients’ behaviors and their valued actions. This is accomplished by asking patients to assess how consistent their current behavior is to the meaningful aspects of life they have identified in therapy. By a series of writing assignments on the relationship between current actions and these values, awareness is increased of specific valued actions in which patients can engage, with the aim of raising the frequency of these behaviors in real life.28

The efficacy of ABBT has been evaluated in two studies. In an open trial, ABBT resulted in significant improvements in worry, anxiety, and depressive symptoms at posttreatment and 3-month follow-up.29 A second study, examining ABBT to a delayed treatment control condition, demonstrated comparable results.30 Statistically significant reductions on clinician-rated and self-reported GAD symptomatology were maintained at 3- and 9-month follow-up. In addition, effect sizes were large, as 78% no longer met diagnostic criteria for GAD, and 77% of the patients reached high-end-state functioning.

Integrative Therapy

The integrative approach to GAD consists of CBT with integrations from interpersonal and experiential therapies. The additive interpersonal/emotional processing features concentrate on four areas: current relationships; origins of current interpersonal problems; the therapeutic relationship; and avoidance of emotion. The theoretical rationale for targeting these factors is based on accumulating evidence that worry and GAD are strongly connected to deficits in the domains of interpersonal problems and emotional processing31 and on findings that patients with GAD largely ignore their emotions, and even may fear them.32

In the additional treatment program, patients learn to identify interpersonal needs and fears, to develop more adaptive behaviors to satisfy those needs, and to pay moment-to-moment attention to their emotions in order to deeply experience and process uncomfortable emotions. Following a thorough explanation of past and current interpersonal relationships, the program progresses with teaching patients alternative ways to handle such relationships.

One way to change relationally maladaptive patterns is social skills training, in which patients first learn new behaviors by role-playing. Patients then practice those behaviors in real-life interactions. In addition, maladaptive patterns can further be addressed by using the therapeutic relationship (eg, by self-disclosure of therapists about the way patients’ interpersonal behavior is making them feel), with the aim to increase awareness of maladaptive patterns and to model more appropriate interpersonal styles.

At this point, it is important to detect and resolve “alliance ruptures,” which frequently occur when using the therapeutic relationship. Exploring affective processes associated with these ruptures, and providing an emotionally corrective experience in their resolution, are one way to address emotional avoidance and to promote emotional processing. This is further facilitated by encouraging patients to openly communicate disaffiliative emotions and by processing patients’ affective experiencing in relation to past, current, and in-session relationships.33

A recent open trial demonstrated that the approach to integrate CBT with elements from interpersonal therapy and emotional processing significantly decreased GAD symptomatology, with large effect sizes and 83% of patients meeting criteria for responder status, defined as 20% change from pretherapy on at least four of six primary outcome measures. All gains were maintained at 1-year follow-up.33

Well-Being Therapy

A promising new direction in the treatment of GAD is adding a specific component for enhancing well-being. WBT34 stems from increasing awareness that psychological treatment should not only focus on alleviating psychological dysfunction but also on restoring normal functioning and enhancing well-being. More specifically, WBT for GAD starts with the identification of episodes of well-being and the circumstances surrounding them, using self-monitoring in a diary.

Once patients are able to properly recognize these episodes, therapy progresses with cognitive restructuring of thoughts and beliefs leading to premature interruption of well-being and the identification and alleviation of specific impairments in well-being dimensions.35 For instance, if impairments in the area of personal growth have been identified, such as feeling unable to develop new attitudes, or having a sense of personal stagnation, it could be explained to the patient that personal growth comprises being open to new experiences and considering oneself as expanding over time.34

Following such explanations, patients are encouraged to carry out mastery and pleasure tasks, as well as exposure exercises to feared situations, with the goal to lead patients from impaired levels to optimal levels in the dimensions of psychological well-being (eg, seeing oneself as growing and expanding and noticing improvement in self and behavior over time).35

So far, the effectiveness of well-being therapy in the setting of GAD is tested in one preliminary study, comparing CBT only to CBT plus WBT.36 Although both treatments were associated with significant reduction of anxiety, CBT plus WBT produced significant advantages over CBT only in terms of symptom reduction and well-being improvement.

As the gains were maintained at 1-year follow-up, these preliminary results suggest that adding WBT to the treatment of GAD is feasible and has clinical advantages. A possible explanation for the supplementary effect of WBT to CBT is that the use of two therapies in a sequence leads to a more comprehensive identification and, thus, cognitive restructuring of automatic thoughts than that entailed in standard CBT targeting episodes of distress only.34

Motivational Interviewing

Another promising innovative strategy to improve response rates in the treatment of GAD is the addition of a motivational pretreatment, motivational interviewing (MI), to CBT for GAD.37 Several studies have demonstrated that patients with GAD are ambivalent about relinquishing worry because they see worry as a problem but hold positive beliefs about the usefulness of worrying at the same time.18

MI is a client-centered, directive approach designed to increase intrinsic motivation and decrease ambivalence about change through treatment. It consists of four key principles:

  • Express empathy;
  • Heighten dissonance between undesirable behaviors and values that are inconsistent with those behaviors;
  • Move with resistance rather than confronting it directly; and
  • Encourage self-efficacy.38

Most of the interventions stem directly from client-centered therapy, such as asking open-ended questions and listening reflectively. MI encompasses one specific, directive technique, eliciting and reinforcing “change talk.” Furthermore, decisional balance procedures are employed to help patients explore the pros and cons of change.

Results of a recent preliminary randomized investigation of the efficacy of MI followed by CBT compared with the efficacy of CBT only demonstrated that patients who received the pretreatment showed significantly greater reductions in worry.37 This superiority was driven by a subgroup of patients with a high worry severity before treatment started (49% of the total sample). These findings suggest that the addition of MI as a pretreatment for GAD might only be indicated for this specific group of patients, which has been less responsive to CBT in past research.39


Based on the present empirical evidence, it can only be argued that patients’ subjective deficit — anxious apprehension surrounding a perceived inability to cope with ambiguous and catastrophized outcomes and the emotions associated with them — can be reduced by diverse strategies and that multiple pathways seem to reach the same endpoint. It seems that “targeting some response processes in therapy for a sufficiently long period of time might affect all the other processes involved in the therapy of anxiety.”31

There are some promising innovative strategies derived from GAD-specific theoretical models that seem to further improve the long-term success of CBT. However, although CBT is an efficacious approach and some newer developments appear promising, there are only few direct comparisons of the various treatments and their effects, making it hard to identify which treatment is the best for which patient.

Further, it remains unknown what the most beneficial components of the above-mentioned treatments are. Finally, there is no evidence-based explanation of how or why the various treatments produce change. Therefore, randomized controlled trials directly comparing the various treatment strategies or comparing the various components of CBT and studies focusing on the identification of mediators and mechanisms of change are urgently needed. Such studies should preferably be carried out by independent research groups, as, so far, most of the studies have been carried out by the researchers who developed the treatments, which holds the risk of “researcher allegiance.”

There are some further problems regarding the empirical support for the treatment of GAD that should be mentioned. First of all, given that the available data almost exclusively concern adult patients, it cannot be assumed that the established efficacy of treatment of GAD applies to children and older adults (ie, 60 years and older). Results of several trials on treatment of older patients with GAD are promising, although, overall, responder rates have been somewhat lower than those reported in studies with younger adults.40 Further investigation in controlled trials is warranted.

This recommendation is certainly true for the treatment of children with GAD, as no studies have been carried out examining the efficacy of CBT in a sample consisting only of children. A second problem is that not all patients with this anxiety disorder can be engaged in psychological treatment. If they do engage in treatment, more than half of them do not respond well. For the first group of patients, adding MI as a pretreatment might be a good remedy.

An alternative strategy would be to explore if these patients are willing to engage in pharmacotherapy. For the latter group (the nonresponders and partial responders), well-being therapy after CBT might improve treatment results and their stability. Another strategy that might improve treatment outcome is trying different empirically supported approaches in a sequence.

For instance, after a moderate response to a standard CBT package, the therapist might move to MCT, and, if necessary, to IUT. If this strategy is unproductive, pharmacotherapy might be considered, alone or in combination with one of the empirically supported psychological approaches for GAD. Future research is needed to establish whether these strategies would improve response rates for non-responders and partial responders.


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CME Educational Objectives

  1. Outline the components involved in cognitive behavioral therapy for generalized anxiety disorder.

  2. Describe innovative treatment approaches for generalized anxiety disorder.

  3. Explain treatment strategies to patients with generalized anxiety disorder.

Sidebar 1.

PsychoeducationSelf-monitoringStimulus control techniquesRelaxationSelf-control desensitizationCognitive restructuringWorry exposureWorry behavior modificationProblem-solving

Sidebar 2.

Stand-alone Treatments:CBT based on the Intolerance of Uncertainty model (IUT)Metacognitive therapy (MCT)Massed worry exposureAcceptance-based behavior therapy (ABBT)Additional Treatments:Integrative psychotherapyWell-being therapy (WBT)Motivational interviewing (MI)38


Jürgen Hoyer, PhD, is with the Department of Clinical Psychology and Psychotherapy, Technische Universität Dresden (Germany). Colin van der Heiden, PhD, is with the Outpatient Treatment Centre PsyQ, Rotterdam, The Netherlands. Michael E. Portman, DPhil, LISW-S, is with the Cleveland Veterans Administration, Case Western Reserve University, Cleveland, OH.

Dr. Hoyer and Dr. van der Heiden have disclosed no relevant financial relationships. Dr. Portman has disclosed the following relevant financial relationships: Springer Science: Royalty recipient.

Address correspondence to: Jürgen Hoyer, PhD, Technische Universität Dresden, Klinische Psychologie und Psychotherapie, Hohe Str. 53, D-01187 Dresden, Germany; fax 49-351-46336955; or e-mail:


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