Reprinted with pennission from the publisher,

Guilford Press, pages 171-200, chapter 7, 1996,

Cognitive Behavioral Treatment of Social Phobia and
Generalizad Anxiety Disorder, Drs. Otto and Gould.

7
Cognitive-Behavioral
Treatment of Social
Phobia and Generalice d
Anxiety Disorder
ROBERT A. GOULD
MICHAEL W. OTTO

Relative to panic disorder, social phobia and generaliied anxiety disorder

(GAD) have received considerably less empirical attention over the last
decade. Social phobia was identified in the mid-1980s as a "neglected anxi-
ety disorder" that was expected to move into the limelight during the 1990s
(Liebowitz, Gorman, Fyer, & Klein, 1985); and, despite characterizations
of GAD as the "basic" anxiety disorder, it has continued to receive less
attention than other disorders. Nonetheless, speciali:ed forros of cognitive-
behavioral treatment (CBT) for these disorders have been developed and
validated, and these offer promising outcome to patients with these
problems. This chapter reviews the nature and efficacy of CBT for social
phobia and GAD, and discusses strategies for optimizing treatment outcome.

SOCIAL PHOBIA

General Considerations

In many ways, social phobia represents an extreme form of the shyness,

performance anxiety, or stage fnght that most individuáis have experienced
at some point ¡n their Uves. It is characterized by fears of humiliation or

171

43
 172 ANXIETV DISORDERS
cmbarrassment ¡n social or performance situations—fears that rcsult in the
regular provocation of anxicty and intcrfercncc in such situations. Social
phobia may include physical symptoms rcsembling thosc of panic disord-
er: incrcased heart rate, hot flashes, sweating, shaking, trcmbling, short-
ncss of breath, and abdominal distress. Although anxicty in social situations
may quickly crescendo into a "panic attack," social phobia and panic dis-
order are distinguished by the focus of thc fcars in each disordcr (Ball,
Otto, Pollack, Ucccllo, & Roscnbaum, 1995; Mannuzza, Fycr, Liebowitz,
&. Klein, 1990). The panic attack and its pcrceivcd consequcnces are the
focus of the fear in panic disordcr, whercas conccrns about humiliation
and cmbarrassment in front of others are dominant ¡n social phobia, and
thcrc is typically no fcar whcn activitics are pcrformcd alone.
Oftcn thcsc physical symptoms are preceded and triggcrcd by maladap-
tive cognitions in which patients may (1) undcrestimate their ability to
cope in social situations (e.g., "1 am certain that my mind will go blank
when I try to givc this spcech"); (2) cxaggeratc thc perceivcd consequcnces
of performing inadcquatcly in social situations (c.g., "If my face turns red
whcn I ask Bonnie out for a date, shc will never want to go out with me");
and/or (3) rchearsc sclf-dcfeating and global attributions about thcmselvcs
and thcir futurc social behavior (c.g., "1 am a social failurc and am des-
tined to be a misfit"). Behavioral corrclatcs typically consist of avoidancc
bchaviors (e.g., skipping class, avoiding calling somconc for a date, or avoid-
ing a party or a convcrsation).
Data from three cpidcmiologic studics indícate that thc prcvalence
of social phobia in the general population ¡s 2-3% (Myers ct al., 1984;
Pollard &. Hendcrson, 1988; Schneier, Johnson, Hornig, Liebowitz, &.
Weissman, 1992). As such, it is thc most common anxiety disordcr and
onc of thc most common psychiatric disordcrs. An evcn largcr perccn-
tagc of individuáis (20%) rcport problcms with social anxicty, but do not
mect thc diagnostic criteriá for social phobia (Pollard &. Hendcrson, 1988).
It is not uncommon for individuáis with social phobia to suffcr from comor-
bid problems. Liebowitz ct al. (1985) reportcd that roughly 20% of thc
social phobics in their study sample mct thc criteriá for alcohol dcpen-
dcnce or abuse, and that approximatcly onc-third prcscntcd with major
depression. Ross (1994a) paints an cqually clisturbing picturc of the livcs
of social phobia patients and describes individuáis who avoid Jobs that
requirc social contact, fail to dcvclop sustaincd friendships and rclation-
ships, forgo carecr promotions that may potentially require incrcased so-
cial contact, and ¡solatc themsclvcs from others outside of thcir ¡mmcdiatc
families. Turner, Beidel, Dancu, and Kcys (1986) found that 92% of a sample
of social phobia patients fclt that thcir anxicty has interfcrcd with occupa-
tional performance, and that 69% wcre unable to attend common social
events. Some social phobics describe years of extensivo and unncccssary
medical cxaminations to find thc cause of symptoms associatcd with thc
disorder, such as exccssivc sweating or difficultics in urinating (Craskc,
Barlow, ók O'Lcary, 1993).
Cognitive-Behavioral Treíilmenl o¡ Social Pliobin and CAD 173
Thc age of onsct for social phobia is gencrally betwcen 15 and 20 years
(Liebowitz ct al., 1985; Turner, Beidel, & Townsley, 1992). The increas-
ing social prcssurcs and social scrutiny during adolescence may contribute
to onset during this lifc phase. Although onset of social phobia is early
rclative to othcr anxicty disordcrs, treatmcnt-sceking behavior is not.
In a rcvicw of 17 studics, Heimbcrg (1989) found that the mean age of
subjccts sccking trcatmcnt ranged from 27 to 41 years, and that thc mean
duration of phobia ranged from 8.2 to 22.1 years. Individuáis prcsenting
for treatment are as likcly to be mcn as womcn (Ost, 1987; Heimberg,
1989).
Subtypcs and Diagnostic Issucs
Clinical rcsearchcrs havc notcd that somc individuáis with social phobia
tend to havc fcars about social intcraction that cxtcnd across a variety
of situations (c.g., public speaking, introducing themselvcs to others, eat-
ing in front of others) and individuáis (e.g., authority figures, dates, strangers)
(McNcill &. Lewin, 1986; Spitzcr ók Williams, 1985). Both the revised
third and fourth editions of thc DíagnoJtíc and Síaiislícal Manual of Mental
Disorders (DSM-11I-R and DSM-IV; American Psychiatric Association,
1987,1994) have incorporatcd this "subtypc" into their diagnostic nomen-
claturc and dcsignated ¡t "social phobia, gencralizcd." Patients who do not
have gcneralizcd social phobia tcnd to prescnt on a continuum of severi-
ty, ranging from those who have problems in onc circumscribcd arca (e.g.,
public speaking) to those with incrcasing numbcrs of problem arcas. Re-
search has suggcsted that gencralized social phobics report grcater fear of
ncgative evaluation, grcater social avoidance, and more depression than
social phobics with more discrctc problems (Heimbcrg, Hopc, Dodgc, ¿k
Bcckcr, 1990b). Turner et al. (1992) also found that generalized social
phobics tended to be more severcly impaired and to pcrform more poorly
on behavioral avoidancc tests. Collectively, these findings suggest that
gencralizcd social phobics may havc grcater difficulty responding to treat-
ment, and may requirc more specialized or intensive treatment intcr-
vcntions.
A scconcl diagnostic issuc relates to thc rclationship bctwccn social
phobia and avoidant pcrsonality disorder. Avoidant pcrsonality disorder
¡s defined as a pcrvasivc pattcrn of social discomfort and fcar of negative
evaluation ¡n which individuáis avoid social and intcrpcrsonal contact and
are easily hurt by criticism and disapproval of others. Studies have sug-
gcsted that there is a largc degree of ovcrlap bctwccn the two disordcrs.
Thc perccntagc of social phobics who also meet thc criteriá for avoidant
pcrsonality disorder has ranged from 20% to 90% (Heimberg, 1989), with
thc highcst rates cvidcnt for generalized social phobics. This markcd overlap
blurs thc diagnostic distinctivcncss of thcsc two disorders and raises qucs-
tions of whethcr avoidant pcrsonality disordcr simply rcprcscnts a more
extreme versión of generalized social phobia.
 ¡74 ANXIETY DISORDERS
Cognitivc-Behavioral Models of the Disordcr
Early bchavioral treatmcnts for social phobia wcre groundcd in thc bclief
that the disordcr reflcctcd a bchavioral déficit that could be rcctificd with
social skills training. Lacking social skills, paticnts wcre prcsumed to find
intcrpersonal intcractions more avcrsive; this was bclievcd to prompt
avoidance, which would furthcr undcrminc thc acquisition of more cffcc-
tive social repcrtoires. Training typically involvcd use of instruction, par-
ticipant modcling, corrcctivc fcedback, role plays, and thcrapist-assistcd
in vivo practicc.
Research on thc effcctivcncss oí social skills training alone has sug-
gcstcd only modcst outcomc. Somc studies havc found no diffcrcnccs bc-
twccn social skills training and attcntion placebo controls (Marzillier,
Lambert, &. Kellett, 1976), and havc found that social skills training
does not gencralize well to in vivo performance tasks (Falloon, Lloyd, Si
Harpin, 1981). Othcrs havc had more promising results, in which pa-
ticnts rccciving social skills training cxhibit modest dccreascs in social
anxicty, avoidance, and distrcss at posttreatmcnt (Lucock &. Salkovskis,
1988; Stravynski, Marks, 6k Yule, 1982). In general, conceptualizations
of social phobia as a skills déficit problcm may fail to incorpórate cogni-
tivc and affective aspccts of thc disordcr that may be important for
treatmcnt.
Within thc past 5-10 ycars, cognitivc-bchavioral modcls of social pho-
bia have bccome incrcasingly multidimcnsional, and thc treatmcnts as-
sociated with thcm havc accordingly bccome more comprchcnsivc.
Hcimbcrg and Barlow (1991; Barlow, 1988) havc proposcd a modcl of so-
cial dysfunction in social phobia that focuscs on thc intcraction of ncga-
tive affect, expectancies, and cognitions in thc maintcnance of the disorder.
This model purports that an individual with social phobia cntcrs social
situations with a real or perccivcd history of ncgativc social interactions,
which can contributc to ncgativc affect and to expectancies of failurc or
embarrassmcnt. Ncgativc expectancies may occur in the form of perccivcd
lack of control (c.g., "1 am going to be unablc to stop mysclf from sweat-
ing and shaking") or in more general forms (c.g., "I am going to cmbarrass
myself," "Shc will notice that I am sweating and think that thcrc is somc-
thing wrong with me"). Thcsc prcdictions of ncgativc outcomc are likcly
to rcsult in hcightcncd autonomic arousal in social situations. As thc in-
dividual cntcrs thc social situation, his or hcr attentional focus thcn shifts
away from appropriatc social cues and toward the adverse conscqucnces
of poor social performance or othcr distracting issucs. Rathcr than focus-
ing on thc social cues in thc situation and thc ongoing social intcractions,
the pcrson focuses on anxicty symptoms (c.g., thc levcl of hcart ratc, thc
level of sweating, thc trcmbling of thc hands) orón cognitivc cues of per-
ccivcd failure (e.g., "I can fccl my face turning red," "I will ncvcr gct anothcr
date in my life"). This shift in turn Icads to grcater mercases in autonomic
arousal, thcreby raising anxiety and motivating avoidancc or escape. Bc-
CiignitivC'Uehavimal Trcalmení vf Social Phobia and CAO 175
cause thc individual is not focusing on appropriatc social cues, this may
in turn lead to dysfunctional orsuboptimal social performance. Lastly, thc
social phobic adopts avoidance as thc primary method of coping with fu-
turc social situations, and maintains his or hcr negativc expectancies with
rcgard to thcsc situations.
For thc socially functional person, this pattern is quite diffcrcnt. So-
cial performance is considcrably less connccted to dysfunctional expec-
tancies and ncgativc affect in such individuáis. Instcad, thcy approach thcsc
situations with gencrally positivc expectancies, bascd on thcir past social
histories. Within thc social situation, thcy focus on appropriatc social cues
and are ablc to compénsate for ¡ncrcascd autonomic arousal with increascd
attentional focus on such cues. This aids thcm in social performance and
provides thcm with gcnerally positivo fcedback. Thc result is an adcquatc
and nonavcrsivc social performance, which encourages thcsc individuáis
to approach futurc social intcractions (Hcimbcrg &. Barlow, 1991).
Thc markcd contrast bctween these two pattcrns of social bchavior
cmphasizcs thc levcl of impairmcnt in many social phobics. Thcir pat-
tcrns of scvcre sclf-evaluation and overwhclming anxicty créate a sclf-
fulfilling prophecy of poor performance, anxicty, and avoidancc. Givcn
thcse sorts of ncgativc cognitivc biascs, it is easy to sec why dysthymia
and dcprcssion may wcll co-occur with social phobia. Comorbid alcohol
problcms are also not uncommon. Not surprisingly, social phobics may
at times turn to alcohol as an apparcnt attcmpt to sclf-mcdicatc thcir anxicty
by decrcasing thcir own social awarcncss and self-cvaluation (Kushncr, Shcr,
&. Bcitman, 1990; Otto et al., 1992). Unfortunatcly, thc cffects of alco-
hol are short-livcd and, bccausc of state-depcndcnt Icarning, do not gcner-
alizc wcll bcyond a nonintoxicatcd statc.
Cognitivc-Behavioral Treatmcnt
Thc general goal of CBT for social phobia is to hclp patients brcak out
of thcir sclf-dcfcating pattcrns and bchavc more adaptivcly in social situa-
tions. Consistcnt with the modcl dcscribcd abovc, treatmcnt focuscs on
hclping patients elimínate thcir anxiogcnic cognitions and rcdircct thcir
attcntion to more rclcvant cues. Avoidancc is also targctcd, bccause of
its role in dcnying paticnts thc opportunity to challenge inaladaptivc anxio-
gcnic thoughts and rcccivc corrcctivc fcedback. Group treatmcnt may be
particularly cffcctivc bccausc of thc built-in cxposurc that it providcs and
thc opportunitics for obscrvational Icarning and contact with individuáis
having similar conccrns and goals. Programmed simulations of thc cvents
that provokc social phobia are more acccssiblc within a group format. Whcn
thcse general stratcgics are used, thc fcar and avoidancc cyclc can be brokcn,
and thc paticnt can dcvclop more functional cognitivc and bchavioral
responsos to social situations.
One of thc more comprchcnsivc and cmpirically bascd forms of CBT
for social phobia was dcvcloped by Hcimberg and his collcagucs (Hcim-
176 ANX/ETV DÍSORDERS
berg, 1989; Hcimbcrg &. Barlow, 1988; Hcimbcrg ct al.. 1990a). This
12-week cognitivc-bcbavioral group trcatmcnt (CBGT) has (bur basic com-
ponents. First, paticnts are educatcd about social phobia and presentcd
with a model (dcscribed abovc) of hovv thcir problcm is inaintaincd. The
interaction among cognitive, physiologic, and behavioral components is
describcd, as well as how these components escálate during a problem-
matic social situation. Particular cmphasis is placed on the notion that
social phobia is a learncd response, and as such can be unlcarned through
behavioral cxposure and cognitive restructtiring. Group mcmbers are asked
to share examples of how social phobia has influenccd thcir livcs, and to
develop a hierarchy of aversive social situations that will be used for later
exposure simulations. For many paticnts, adjustmcnt to the group sctting
is the first aspcct of exposurc trcatment, and opcn discussion of thcir anxicty
about participating in the group is cncouragccl by the group leader.
In weeks 2 and 3, patients are taught the fundamentáis of cognitive
rcstructuring that will be used in the remaining treatmcnt scssions. Pa-
tients are instructcd on how to rccognizc distortions in their thinking during
social situations and social performance (e.g., fortunc-tclling errors, mind
rcading, all-or-nothing thinking), and to develop cognitive rcsponscs to
thcir thoughts that crcdibly challenge thcsc errors. Hypothcsis-tcsting procc-
dures are used to encourage paticnts to come up with more accuratc and
honcst appraisals of thcir performance and public perccption. Thesc tech-
niques are designcd to help paticnts idcntify and changc their cxpecta-
tions of ncgativc social outcomcs and thcir rclatively scvcrc cvaluations
of themselves in social situations. Paticnts rehearsc idcntifying thcsc er-
rors and creating countering thoughts in session; thcy are also askcd to
monitor their thoughts during social interactions in the coursc of the sub-
scquent wcck.
The remaining ninc scssions of CBGT consist of complcting cxposure
simulations of personally rclcvant situations and assignmcnts of ¡n vivo cx-
posure homework. Exposurc simulations rcquire that paticnts rolc-play in-
crcasingly difficult fcared situations in the group setting, using other group
members to try to make these situations as truc to lifc as possible. Thesc
exposures are designcd to provide paticnts with opportunitics to expcriencc
arousal ¡n social situations, to learn to rcspond diffcrcntly to this arousal,
and to leam that their anxicty will decrcasc with practicc. Patients also
have the opportunity to challenge cognitive distortions in these situations
and to practice adaptive coping statcments. The group sctting provides
an audience and role players for these intcrventions, which may include
simulations of convcrsations, giving a specch, or eating a messy food. With
succcssful trcatment, paticnts learn of the scverity of thcir cognitivc dis-
tortions about fearcd situations, develop skills for identifying and corrcct-
ing thesc distortions, and gain cxpcricnce at pcrfonning in such situations
(with particular practice in corrccting and identifying distortions bcfore,
during, and after these programmed exposurc simulations). As the group
continúes, exposure practice is expandcd, hclping paticnts develop confi-
Cngnitive-Deliaviinal Tr«miirni n( Social fhobia and CAO 177
dencc and competcnce in a widcr varicty of social situations and hclping
them change the cognitive biascs that led to anxiety in the first place.
Homework assignments rcquirc that patients practicc thcir newly acquired
skills betwccn sessions and report back to the group on their succcsses and
difficultics. Group sizc is typically ftvc to scven paticnts, and sessions last
for 2'/2 hours to insure that cach patient will expcrience several exposure
simulations by the end of trcatment (Heimberg &. Barlow, 1991).
Trcatmcnt Outcome Findings
Outcomc for CBGT and Ot/ier Forms o/ CBT
Studies asscssing the cffcctivcness of CBGT havc reponed favorable rcsults.
In a comparison of CBGT to an educational-supportive psychotherapy
program, improvcmcnts wcre found for both groups, but the paticnts receiv-
ing CBGT werc significantly more improved than the trcatment control
at both posttreatment and follow-up (Heimberg ct al., 1990b). Seventy-
five pcrcent of patients unclcrgoing CBGT mct critcria for clinical im-
provcmcnt bascd on a phobia scverity rating scale; by the education-
al-supportive program resultcd in a 40% improvemcnt rate. Clinical benefit
was inaintaincd and, in fact, incrcascd over the 6-month follow-up pcri-
od: 81% of CBGT-treatcd patients met the clinical critcria for improve-
ment at the follow-up assessinent. Consistcnt with a cognitive-bchavioral
formulation of the disordcr, dccreases in phobic severity for social situa-
tions \vcrc associatcd with the dccreases in ncgativc self-evaluations.
A number of other studies have examined the effcctivencss of othcr
cognitive and behavioral techniques, used cither alone or ¡n combination.
Studies cmploying social skills training have found that thcsc proccdures
are associated with improvemcnt in paticnts who are defined as both so-
cially phobic and socially ¡nadequatc, but they may be more cfficacious
for unskilled than for overanxious paticnts (Heimberg & Barlow, 1991;
Óst, Jerrcmalm, & Johansson, 1981). Interventions employing relaxation
training techniques havc obtaincd mixcd results. Alstrom, Nordlund, Pcrs-
son, Harding, and Ljungqvist (1984) comparad relaxation training to ex-
posurc, supportive thcrapy, and a control condition. The authors reported
that relaxation training was incffectivc, doing more poorly than the cx-
posure and supportive therapy conclitions, and no bctter than the control
condition. Studies using applied relaxation have farcd bettcr. Óst ct al.
(1981) compared applied rclaxation to standard progrcssivc musclc relax-
ation and found that subjccts rccciving applicd relaxation were signifi-
cantly more ¡mprovcd on most mcasurcs than the group receiving
progrcssivc musclc rclaxation.
Studies comparing the cffcctivcness of bchaviorally bascd cxposure
trcatmcnts to CBT havc failcd to demónstrate consistcnt superiority of
the latter. Butler, Cullington, Munby, Amies, and Geldcr (1984) com-
pared exposure thcrapy to exposure therapy plus anxiety managemcnt train-
 ¡78 ANXIETY DISORDERS
ing and to a waiting-list control group. At posttreatmcnt, both treatment
groups werc significantly differcnt from thc waiting-list control on meas-
urcs of phobic severity, anticipatory anxicty, social avoidance and distress,
and dcpression. Emmclkamp, Mcrsch, Vissia, and van dcr Hclm (1985)
assigncd subjccts randomly to in vivo cxposurc, rational-cmotivc thcrapy,
and self-instruction training in which subjccts practiccd gcncrating adap-
tive cognitive rcsponscs. Rcsults indicatcd that all thrcc trcatmcnts wcrc
cqually cffectivc at rcducing social fcar and distrcss. Mattick, Pctcrs, and
Clarkc (1989) found that paticnts receiving cxposurc alone pcrformcd bcttcr
on mcasures of bchavioral approach than did paticnts receiving cognitive
rcstructuring alone, but worsc on mcasures of attitudinal changc. Othcr
studies havc also indicatcd that cxposurc trcatmcnts yicld rcductions in
social phobics' anxiety and avoidance (Biran, Augusto, Si Wilson, 1981;
Mattick ¿k Pcters, 1988).
CBT venus Pharmacologic /ntervcntions
Few comparisons betwccn CBT and pharmacologic intcrvcntions are avail-
able. Gclernter ct al. (1991) comparcd a group form of CBT (not Heim-
bcrg et al.'s CBGT) to pharmacothcrapy (with alprazolam, phcnclzinc, or
a pill placebo) plus instructions for cxposurc to phobic stimuli. All of the
trcatments wcrc associatcd with significant improvcmcnt (mcasurcd by
changcs in sclf-rcport instruments and physician rating scalcs), and no one
treatment was consistcntly superior to thc othcrs. Intcrprctations of these
findings are limitcd, howcvcr, bccausc paticnts in all of thc drug treat-
ment conditions were instructcd to complete sclf-dircctcd cxposurc to fearíul
social situations. This instrucción hclpcd to ¡nsurc that cxposurc intcr-
vcntions wcrc common to all treatment conditions, thus raising thc pos-
sibility that cxposure was thc active treatment clemcnt for tliis study. In
anothcr study, cxposurc alone, in thc form of 20 scssions of imagina! and
m vivo flooding, was comparcd to thc drug atcnolol and to a drug placebo
condition (Turner, Beidel, & Jacob, 1994). Thcsc researchcrs found that
flooding was consistently superior to placebo, whcreas atcnolol was not.
In addition, flooding was superior to atenolol on bchavioral and compo-
sitc outcome measurcs. More reccntly, Hcimbcrg ct al. (1994) comparcd
CBGT to phcnclzinc and to a pill placebo. At posttreatmcnt (12 wceks),
both CBGT and phcnelzinc were superior to placebo, but not differcnt
from each other. Phenelzine had a faster onset of thcrapcutic cffcct than
CBGT by weck 6, but this diffcrcncc was climinatcd by thc cnd of
treatment.
Meia-Analyííc Fmdings
Mcta-analysis is a statistical tcchniquc that allows comparison of treat-
ment results in tcrms of quantifiablc units (callcd "cffcct sizcs") bascd on
thc normal curve. Thc advantíigc of mcta-analytic procedures is that thcy
Cogiiiiivc-Dc/uivicmiI Trcmmcm o/ Social Phabia and GAO 179
yicld standardizad scorcs (cífect sizcs) that can be uscd as a common met-
ric across scvcral treatment outcome studies using differcnt treatment out-
come mcasures. To provide a summary of thc litcraturc to date, we reccntly
conductcd a mcta-analysis of 24 studies that uscd psychosocial or phar-
macologic intcrvcntions for social phobia (Gould, Buckminstcr, Pollack,
Otto, & Yap, 1994). All studies cmployed treatment control conditions,
and bctwccn-group effcct sizcs wcrc calculated rclativc to thcsc control
conditions. In addition, ¡n ordcr to reduce mcasurcmcnt bias, effect sizes
wcrc only dcrivcd from sclf-rcport qucstionnaircs. Thrcc cffcct siics wcrc
calculated for cach social phobia study to capture thrcc symptom dimcn-
sions of social phobia: social anxicty or avoidance, cognitive changc, and
dcpression. Results of this mcta-analysis are presentcd in Table 7.1.
Ten studies provided data on thc efficacy of pharmacothcrapy rela-
tivc to pill placebo (n = 8 studies), pill placebo plus cxposure instructions
(n = 1 study), or a no-treatmcnt control group (n = 1 study). Thc mean
effect size for social anxiety was 0.62 and for depression was 0.83. Mcas-
ures of cognitive changc wcrc asscsscd in only onc study. Comparisons
of thc social anxiety and dcpression effect sizes to the nuil hypothesis (cf-
fcct sizc = 0.0) werc statistically significant. In addition, eliminating thc
two studies that did not use puré pill placebo control groups did littlc to
changc thc ovcrall cffcct sizcs (0.52 for social anxicty; 0.88 for dcprcssion).
Thc mean dropout ratc for thcse studies was 14.9%.
Monoaminc oxidase inhibitors (MAOIs) in this mcta-analysis includ-
cd phcnclzinc (n •= 4 studies) and moclobcmidc (n = 1 study), and thcir
mean social anxicty effect size was 0.64 with a dropout rate of 14%. Two
controllcd studies assesscd the efficacy of high potcncy bcniodiazcpines
(BZDs; alprazolam and clonazcpam); thcir mean cffcct sizc was 0.72, and
thcir dropout ratc was 12%. Promising results wcrc obtaincd from SSRls
TADLE 7.1. Mcta-Analysis oí Acutc Trcatmcnt Outcome
for Social Phobia
Mean social anxicty
Treatment intcrvcntion • cffcct sizc
Pharmacothcrapy vs. pill placebo
MAOIs (5 studies) 0.64
Beiuodiazcpincs (2 studies) 0.72
SSIUs (2 studies) 1.89
Bcta-adrcncrgic blockcrs (3 studies) -0.09
Duspironc (I study) -0.50
CBT vs. controls
Cognitive rcstructuring alone (3 studies) 0.60
Exposurc tcchniqucs alone (6 studies) 0.89
Exposurc plus cognitive rcstructuring (8 studies) 0.80
Note. Thc numbcr oí studies proviiling outcome comparisons is notcd íor each Ircal-
mcnt usted, h'torn Gould, Ouo. Yap. and Pollack (1991).
180 ANX1ETV DISORDERS
including fluvoxaminc (n = I study) (effcct size = 2.73; dropout ratc =
3%) and scrtraline (n - 1 study) (effect size - 1.05; dropout rate = 0%).
The beta-adrenergic blocker atcnolol (n = 3 studics) (effect sizc = 0.09)
and buspirone (n = I study) (cffcct size = - 0.50) did not appcar to be
effcctive for social phobia bccausc thcy did worse than a pill placebo con-
dition.
Studies of cognitive-bchavioral thcrapy utilizcd cognitivc restructur-
ing, situational exposure, social skills training, systematic dcsensitization,
flooding, and anxicty management tcchniqucs. A total of 16 studics uscd
cognitive-behavioral intcrventions without pharmacotherapy, and their
mean social anxiety effect size was 0.71, the mean cogntive change effect
size was 0.74, and thc mean dcprcssion effect sizc was 0.67. Thc mean
dropout ratc for CBT intervcntions ¡n thesc studics was 11.5%. In gener-
al, therc werc no significant diffcrcnccs bctwccn typcs of CBT intcrven-
tions, and all were superior to the nuil hypothcsis (cffcct size = 0.0). Studies
using cognitive restructuring alone (effect size = 0.60) did not differ sig-
nificantly in cfficacy from studics using exposure techniqucs alone (effect
size - 0.89) or the combination of exposure plus cognitivc restructuring
(effect size = 0.80), ñor did thcy differ ¡n terms of dropout ratcs.
Comparisons of studics utilizing cognitive-behavioral trcatmcnts (ef-
fect size = 0.71) to those using pharmacotherapy (cffcct size - 0.62) were
not statistically significant. In addition, mean attrition ratcs werc not sig-
nificantly differcnt among subjects receiving a cognitive-behavioral inter-
vention (11.5%) and those receiving a medicación intcrvcntion (14.9%).
CBT intcrventions may also cnjoy a small advantage ¡n tcrms of thcse
comparisons due to thcir use of wait-list controls, which tend to be wcak-
cr control conditions rclativc to pill placebo conditions.
Results from our mcta-analysis are similar to findings by Chamblcss
and Gillis (1993). Thesc authors derived cffcct sizes bascd on within-group
change from prc- to posttrcatmcnt in 10 studies of CBT for social phobia.
Thcy found large effect sizcs for CBT at thc end of trcatment. In addi-
tion, thcir rcview of controlled rcscarch studics indicatcd that CBT-treatcd
paticnts did significantly bcttcr on most measurcs than did thcir control
cohorts. For measurcs of social phobia, thc prc-to-post cffcct sizc was 0.68;
for measurcs of fcar of ncgativc cvaluation, thc cffcct sizc was 0.70.
Long-Tcrm Residís
Only four studics using cognitivc and bchavioral tcchniques have includ-
cd data with follow-up periods of 1 ycar or longer. Fava, Grandi, and Canes-
trari (1989), in an uncontrolled trial of the effccts of exposure trcatment
alone for 10 social phobia patients, reportccl that 7 of the 10 hacl main-
taincd thcir posttrcatment gains at a 1-ycar follow-up. Mcrsch, Emmclkamp,
and Lips (1991) uscd a 14-month follow-up on a study that originally com-
pared social skills training with rational-emotive thcrapy. At posttrcat-
ment, both groups showed improvcment on a numbcr of outcomc measurcs.
Cognitive-Behavioral Treaimcni of Social Phobia and CAO 181
Although subjects generally maintaincd thcir trcatment gains at follow-
up, 44% of thcm sought and obtaincd additional trcatment for their so-
cial phobia during this time pcriod.
Wlazlo, Schroedcr-Hartwig, Hand, Kaiser, and Munchau (1990) com-
pared a social skills training program to individual and group-administered
in vivo exposure trcatmcnts. Results suggcsted no significant differcnces
betwccn thc two conditions and general improvcment for thc majority
of patients. Long-term asscssmcnts were conductcd betwecn 1 and 5.5 ycars
(mean = 2.5 ycars), and the authors reported additional improvements
on several measures for both groups at follow-up. It should be noted,
howcver, that methodologic problcms cxistcd in thisstudy: Paticnts were
not randomly assigncd to groups, and patients in thc social skills training
condition werc also taught exposure tcchniqucs.
Heimbcrg ct al. (1990a) compared a crediblc placebo (an educa-
tion-support group) to CBGT and found that 75% of CBGT patients met
thc criteria for clinical improvemcnt at posttrcatment, comparcd to 40%
of the placebo group. Data from this study represent the longest mean
follow-up pcriod (mean = 5.5 ycars; range - 4.5 to 6.25 ycars) and werc
dcrivcd from 19 of the 40 original subjects (Heimberg, Salzman, Holt, &
Blcndell, 1993). The authors indicatcd that their follow-up subsamplc may
havc becn less itnpaired beforc trcatment than nonparticipating subjects,
but also notcd that CBGT and thc placebo trcatment were equivalent
in terms of participant-nonparticipant diffcrcnccs. At follow-up, 89% of
CBGT patients werc judgcd to be clinically improved by independent as-
scssors, comparcd to 44% of the cducation-support group mcmbcrs. More
rccently, Heimberg et al. (1994) reported that although CBGT and phencl-
zine werc equivalent and superior to a placebo at posttrcatmcnt, at 6-month
follow-up thc CBGT subjects had maintaincd thcir improvcment, whereas
onc-half of phcnelzinc paticnts had rclapsed. In summary, results from these
studics suggcst that thc bcncfit from CBT generally endures ovcr time.
Trcatment Rcsistancc/Maximizing Trcatment Outcome
From thc pcrspcctivc of clinical rescarch, rclativcly littlc is known about
what kinds of patients tcnd to be rcsistant to standard forms of CBT for
social phobia. There is somc cvidencc that paticnts with discrcte social
phobia tcnd to bcnefit more from CBGT than do those with gcneralized
social phobia (Heimbcrg, 1989). It is also evidcnt that paticnts who havc
rclatively more skills déficits will bcncfit more from an approach thac em-
phasizcs skills than from an approach that emphasizcs anxiety reducción
(for a rcview, sce Heimberg, 1989). Henee, packagc trcatment approaches
that are able to stress cithcr anxicty rcductíon, skills acquisition, or a com-
bination of thesc intcrvcntions may offer the bcst bcncfit to a hetcrogencous
sample of patients.
The ovcrlap between social phobia and avoidant personality disorder
suggests that paticnts with thc gcncralized subtype of social phobia may
 182 ANXÍETV DJSORDERS
have prominent and fixed pattems of avoidance ¡n social situations, and
henee that treatment may nccessarily rcquire a longcr course of interven-
ción. In addition, ncarly one-tliird to onc-half of some samplcs of patients
with social phobia havc bccn found to havc comorbid panic disordcr
(Barlow, 1988; Roscnbaum &. Pollack, 1994). Often this comorbidity
manifests itself in the form of situationally bound panic attacks, in which
a panic attack bccomcs incrcasingly common under spccific social condi-
tions and then generalizes to othcr social situations. As such, patients ex-
periencc anticipatory anxicty not only with rcgard to fcars of humiliation,
but also with regard to thc expcricnce of uncontrollablc panic symptoms.
Because standard CBGT focuscs the most attcntion on cognitivc rcstruc-
turing, pacicnts with comorbidity may bencfit from thc addition of tcch-
niqucs found to be uscful for panic disordcr, particularly intcroccptivc
exposure techniques. Intcroceptive cxposure—that is, cxposing patients
to thc somatic sensations of anxiety (scc Otto &. Gould, Chaptcr 5, this
volumc)—offers thc therapist thc abtlity to includc in cxposure assignments
not just the extcnsive cues of a social situation, but also rclcvant intcrnal
scnsations of arousal. Treatment can thus focus on dccreasing anxiogenic
rcsponses to both internal and cxternal cues. The addition of othcr symp-
tom managcmcnt skills and cognitivc rcstructuring for panic attacks may
also be of use for thcse patients.
Comorbid dcpression has bccn identificd as a ncgativc predictor of
treatment outcomc (Barlow, 1994). Brown and Barlow (1992) rcportcd that
35% of patients with social phobia had expcricnced at least onc cpisodc
of major dcpression. Stcin, Tanccr, Gclcrtner, Vittonc, and Uhdc (1990)
rcported that 20% of patients with social phobia prescntcd with an addi-
tional mood disordcr (eithcr major dcpression or dysthymia). Comorbid
dysthymic disorder has bccn found in 15% of social phobics (Van Amcrin-
gen, Mancini, Styan, &. Donison, 1991). In more than 80% of cases of
social phobia with comorbid deprcssion, thc depressivc symptoms dcvclop
aftcr thc onset of social fcar and avoidance (Brooks, Baltazar, &. Mun-
jack, 1989; Turncr, Bcidcl, Borden, Stanley, &. Jacob, 1991). Because
comorbid deprcssion tcnds to incrcase thc scvcrity of fcars of negativo evalu-
atton (Ball et al., 1995; Bruch, Mattia, Hcimbcrg, & Holt, 1993), thc ad-
dition of supplcmcntal cognitivc rcstructuring and activity assignmcnts
may be nccessary for thcse paticnts. In particular, wc havc noticcd in oúr
clinical practice that patients with comorbid depression easily becomc
prcoccupicd with global depressivc thoughts about thcmsclvcs and their
performance. For patients with such comorbidity, wc routincly apply ad-
ditional cognitive restructuring skills, as wcll as ¡nformational intcrvcn-
tions to caution thcm about cognitivc biascs that emerge from dcpression
and to help them devclop ways of rcstructuring thesc biases. Howcvcr,
whenevcr dcpression dominates thc clinical picturc, we rcfer paticnts for
CBT for dcpression prior to rcferral for social phobia treatment.
In summary, social phobia treatment is just now rccciving the rescarch
attention that it descrvcs. Treatment studics conductcd to date affirm that
Tri'flimcw uf Social i'iwbkt atol GAD 183
CBT is a powerful intcrvcntion, producing rcsults that rival thc outcomcs
obtaincd with antideprcssant intervcntions. CBT intcrvcntions havc bor-
rowcd thc same principies as thosc identificd for treating othcr anxicty
disordcrs; thcse includc idcntifying bchavioral cxcesscs and déficits, and
providing corrcctivc skills training and cxposure cxpericnccs to elimínate
pattems that maihtain the anxiety disordcr. It appears that cognitive rc-
structuring and cxposure intcrvcntions providc a powerful combination
of interventions for the treatment of social phobia. For a subsamplc of
paticnts who are poorly skillcd ¡n social situations, addítional training ¡n
social skills may providc furthcr bcncfits. As with othcr anxicty disorders,
comorbidity is likcly to rcquire additional and broadcr treatment intcr-
vcntions that includc componcnts of treatments found to be effcctive for
othcr Axis I disordcrs (c.g., panic disordcr or deprcssion).
GENERALIZED ANXIETY DISORDER
General Considcrations
Although GAD has bccn dcscribcd as thc "basic" anxicty disordcr, it has
rcccivcd only minimal rcscarcb attcntion. This phcnomcnon may havc
stemmcd originally from thc lack of wcll-dcfincd diagnostic critcria for
GAD and from its origins as a residual diagnostic catcgory. With thc ad-
vcnt of DSM-1I1 (American Psychiatric Association, 1980), panic disord-
cr was scparatcd from thc anxiety ncuroses, and GAD was dcfincd as a
- discrctc diagnostic catcgory. Identification of GAD as a sepárate disordcr
has cncouragcd systcmatic collcction of data with rcgard to thc phcnomc-
nology and treatment of this condition.
GAD is conccptualizcd as a disordcr of cxccssive worry that manifests
itself in cognitivc, physiologic, and behavioral componcnts. Thc cogni-
tivc and physiologic componcnts providc thc core diagnostic critcria for
thc disordcr. As dcfincd in DSM-1V, the cognitivc component includcs
unrcalistic or cxccssive worry about scvcral lifc circumstanccs occurring
more oftcn than not for at least 6 months (American Psychiatric Associa-
tion, 1994). For examplc, a paticnt may worry about moncy whcn his or
hcr finances are sound; a mothcr may agonize ovcr thc hcalth of a robust
child; or a husband may worry about low-probability catastrophic cvcnts
(c.g., "My wifc's plañe will crash"). Individuáis with GAD often fccl un-
ablc to control this anxious apprchcnsion and it causes significant distrcss
or iinpainncnt in social or occupational functioning.
In accordancc with thcse apprchensivc thoughts, paticnts with GAD
suffcr from physiologic symptoms of anxicty. Thcsc symptoms includc inus-
clc tensión, ¡ncrcascd irritability, difficulty conccntrating, and incrcascd
vigilancc (c.g., difficulty slceping, fccling rcstlcss or kcycd up). Although
some of thcse symptoms ovcrlap with thosc of panic disorder, thcy have
a diffcrcnt profilc: Thcy tcnd to be associated with worry thoughts and
 184 ANX/ETV DISORDERS
are much less likely to occur spontaneously. In addition, GAD patients
without panic disorder are less likcly to be fcarful ofthe physical symptoins
themselves, despitc finding thcm uncomfortablc. Patients with GAD tend
to report anxiety during protractcd pcriods cach day, and are also more
likcly to expcricnce anxiety on more days ofthe week than panic sufferers.
Barlow (1988) found that patients with GAD suffercd from anxicty 56%
oí thc time, which was considcrably more than for patients with panic
disorder (16%). In addition, the majority of individuáis with GAD are symp-
tomatic from the time that they acquire the disorder, with only 25% report-
ing episodcs of rcmittancc of 3 months or longer (Noyes, Clarkson, Crowe,
Yates, & McChcsney, 1987).
Although such behaviors are not part of thc formal cliagnostic critcr-
ia, individuáis with GAD tcncl to cngagc in behaviors that rcinforce and
perpetúate theiranxious worry (Craskc et al., 1993). Behavioral manifesta-
tions of worry often include checking, avoidance, and vigilancc. Specific
examples ¡ncludc rcpcatcdly calling thc family physician about a child's
runny nosc; staying at homc when it is raining lightly for fcar of a car
accidcnt; and instructing children who are outside playing to come in the
house cvery 15 minutes in ordcr for the anxious parent to check on their
safety. Functionally, such behaviors providc immcdiate rclief of anxicty.
In the long term, however, they do not allovv thc normal habituation of
anxiety to occur. In this way, worry bchaviors and worry thoughts rein-
force cach other and can cvolvc into a chronic pattcrn.
GAD is one of the more common anxicty disorders, with prevalcnce
rates varying from 1.6% to 4.0% (Wittchen, Zhao, Kcssler, & Eaton, 1994;
Weissman & Mcrikangas, 1986). Estimates of prevalcnce for individuáis
who cxpericnce cxccssivc worry that does not mect formal Axis I criteria
may be as high as 10% (Shephcrd, Coopcr, &. Brown, 1966). Findings
rcgarding gcndcr differcnces havc becn inconsistcnt, although the most
rccent National Comorbidity Survcy found that thc disorder was twicc
as common in womcn than in mcn (Wittchen ct al., 1994). Age of onsct
is typically ¡n thc late tccns or early 20s (Andcrson, Noyes, & Crowe,
1984; Rickels & Schweizer, 1990; Rapce, 1991); howevcr, paticnts tcnd
to seek initial treatment later than patients with panic disorder (Nisita
et al., 1990). This delay may be attributablc to a paucity of adcquate diag-
nostic and referral proccdurcs at the level of primary care; poor diagnostic
and referral proccdurcs at this levcl; or a bclicf on thc part ofthe patients
that thcir anxiety problcm ¡s a fixccl trait that is not treatable.
Relatively fcw paticnts with GAD are sccn in anxicty disorder clinics
(Dubovsky, 1990). The majority are scen by general practitioners, to whom
they often ¡nitially report complaints of physical anxiety symptoms.
Dubovsky (1990) estimatcd that only 25% of paticnts with GAD rcceivc
specific treatments tailorcd to the disordcr. This pcrccntagc may be evcn
smaller ¡n more rural settings with fcwer mental hcalth profcssionals. Pa-
ticnts with GAD are more likcly to havc cxpcrienccd some rccent stress-
ful life event (e.g., marriage, Job promotion, loss of parent) at the time
Cogiúlive-Bclutvioral Treatmcnt of Social Phobía and GAD 185
that they prescnt for treatment (Blazer, Hughes, & George, 1987). The
percentage of patients diagnosed with GAD who report having rcceivcd
previous psychologic or psychiatric treatment varíes widcly; it ranges from
29% (Power, Jcrrom, Simpson, &. Swanson, 1989) to 94% (Durham ók
Turvey, 1987).
Etiology and Naturc of the Disordcr
As in the other anxicty disorders, a combination of genetic, personality
trait, and life event factors secms to be implicated in the génesis of GAD.
Howcvcr, idcntification ofthe truc ctiologic mcchanisms of this disorder
is hampercd by thc abscnce of prospectivo studics cxamining its onset.
Barlow and his colleagucs havc dcscribed a numbcr of characteristics in
their GAD paticnts that they believc predisposc paticnts to devcloping
thc disorder as well as other anxiety disorders (Barlow, 1988). First, thesc
paticnts are charactcrizcd by highcr levéis of diffusc arousal and sensitiv-
ity than are nonanxious normáis. Second, they possess a cognitive bias
to vicw the world as a dangerous place, and this view is often precipitated
by past life expcrienccs. Other researchcrs have confirmcd that a history
of negativo life experiences may predict later dcvelopment of GAD (Nisita
ct al., 1990). Torgerson (1986) found that GAD paticnts werc more likely
than panic disordcr subjects to havc cxpcrienced the death of a parent
prior to the age of 16. Third, they are more likely to havc hcightcned
bclicfs about rcsponsibility, control, and pcrfcctionism. However, it is not
clcar whether these personality charactcristics are causes or conscquences
of GAD, bccausc of the rctrospective bias of this finding.
Other researchcrs have also lookcd at genetic mediators of GAD. They
report cvidence that the frcquency of GAD ¡s higher in relatives of GAD
probands than it is in relativos of control or panic disordcr probands, and
the frcquency of panic disorder is highcr in relatives of panic disordcr pro-
bands than it is in relativos of control or GAD probands (Crowc, Noyes,
Pauls, &. Slytnen, 1983¡ Noyes ct al.,.1987). However, relatives of panic
disorder, agoraphobia, and control probands wcrc found to be equally at
risk for GAD (Noyes ct al., 1986). It may be that individuáis with GAD
and panic disorder inhcrit a diathcsis to develop anxiety disorders in general.
How GAD is maintaincd after its onsct has bccn thc subject of some
thcorctical debate. A numbcr of authors havc lookcd to cognitive factors
as thc core mechanism of action for this disordcr. Borkovec and his col-
leagucs havc hypothesizcd that worry is primarily characterized by verbal
thoughts rathcr than imagcs and is mcdiatcd by avoidance bf potcntially
distrcssing emotional imagcry (Borkovec &. Inz, 1990). They cite cvidence
that during rclaxation nonanxious controls showcd a prcdominance of im-
agcry, whcrcas GAD subjects showcd cqual amounts of thought and im-
agcry. After successful thcrapy, GAD subjects showed thought and image
frequencies that rcscmbled thosc of normáis. Accordingly, worry ¡s hypothe-
 i 86 ANX/ETV DISORDERS
sizcd to allow thc GAD suffcrcr to escape distrcssing imagcry; bccausc of
this lack of cxposure, thc anxicty associatcd with such imagcry ¡s ncvcr
allowcd to habitúate. Othcr authors havc qucstioncd this conceptual-
izacion and point out that othcr kinds of thinking are at Icast as cffcc-
tive as worry thinking in supprcssing cmotional imagcry (East &. Watts,
1994).
A numbcr of cognitivc biascs may triggcr tlic worry proccss. Thcsc
may ¡ncludc patients' tcndcncy to overcstimatc thc likclihood of thc oc-
currcncc of ncgativc evcnts and thc ncgativc consequcnccs of thesc cvcnts,
and to undercstimacc thcir ability to cope with thcsc cvcnts (Darlow, 1988).
In addition, information-proccssing rcscarch suggcsts biascs in thc way that
GAD pacicncs attcnd to information in chcir environmcnts. Butlcr and
Mathcws (1987) found that individuáis with GAD wcrc more likely to
make thrcatcning intcrprctations of ambiguous materials than wcrc nor-
mal controls, and more likely to ratc thc probability that dangcrous cvents
would occur as high. Mathcws and McLcod (1985, 1986) uscd modificd
Stroop and dichotic listcning tasks to study thcsc information-proccssing
biascs, and confirmcd that paticnts with GAD allocatc proportionally grcat-
cr rcsourccs for dctccting thrcatcning material than normal controls and
can dctcct this material more rapidly.
Individuáis with GAD may also havc a tcndcncy to rnisintcrprct com-
mon ncgativc cvcnts that are part of thc human condition (e.g., occasional
accidcnts, thc dcath of an cldcrly relativo) as evidcncc that thc world is
a dangerous place and that thcir worrying is justificd. This world view is
hypothcsizcd to contributc to hcightcncd vigilancc and to thc belicf that
thcir worrying is adaptivc and prophylactic. In more scvcrc cases, GAD
suffcrcrs may dcvelop a supcrstitious cognitivc schcma that thcy actually
can prcvcnt futurc ncgativc cvcnts by worrying (Dorkovcc, 1985). Thc worry
proccss may be furthcr cxaccrbated by thc suffcrcrs' tcndcncy to shift from
one worry thought or belicf to another vcry rapidly, without giving thcm-
sclvcs che chance to test thc vcracity of thesc thoughts. As such, thcy
bccomc so prcoccupicd with worry that thcy cannot focus thcir attcntion
on finding solutions to thcir problcms, or are unablc to try out potencial
solutions to thcir problcms (Craskc ct al., 1993). In othcr cases, paticnts
with GAD recognizc that thcy are worrying cxccssivcly, and this leacls
thcm to rcsist worrying or to distract thcmselvcs from worrying. Paradoxi-
cally, chis straccgy may havc che oppositc cffcct, in thc way that trying
Co rcsisc thinking about somcthing oftcn makcs it strongcr,
In summary, although thc cxact mcchanism or mechanisms mediat-
ing GAD are still opcn to debate, thc componcnts of GAD that appcar
to concribucc Co che cyclc of worry ¡ncludc (1) cmotional arousal and
information-proccssing biascs to thrcatcning s t i m u l i ; (2) belicf that worry
prcvcncs future ncgativc cvcnts; (3) incffcctivc problcm solving; and (4)
atccmpcs to rcsisc and discracc ncgativc imagcry without rcaching aitcrna-
tivc solutions.
Copiitivc'Bclvivioral Trcaimcm u/ Social Phobia and GAO 187
Cognitivc-Dchavioral Trcatmcnt
Thcre are thrcc basic stratcgics for CBT of GAD: cognitivc rcstructuring
of anxiogcnic thoughts, rclaxation training, and worry cxposure assign-
mcnts, Each of these stratcgics attempts to target clcmcnts of thc worry
cyclc that trigger and maintain thc disordcr. Cognitivc rcstructuring of
anxiogcnic thoughts is at thc foundacion of trcatmcnt for GAD. Thc com-
poncnts of cognitivc rcstructuring are as follows: cducation about thc role
of cognitions in incrcasing anxicty; thc logical cxamination of thoughts;
probability cstimations; and thc use of bchavioral assignmcnts and monitor-
ing Co challenge thc vcracity of anxicty-relatcd bclicfs. Approximatcly onc-
third of thc paticnts prcscnting with GAD to our clinic do not under-
stand thc relationship bctwccn cognitivc and cmotional proccsscs. Thcy
do not undcrstand that thcir anxious mood statcs are oftcn triggcrcd by
cognitions, and that this relationship is rcciprocal (i.e., how thcy fcel can
also affcct what thcy think). Educación about thcsc proccsscs is a first stcp
for such paticnts.
The core clcmcnts of cognitivc rcstructuring focus on tcaching pa-
ticnts a systcmatic inethod for cxamining thc vcracity of thcir thinking
and cstimating thc probability of ncgacivc cvcnts. Paticnts are first instruct-
cd lo use thought records to writc down thcir anxiogcnic thoughts, in ordcr
to examine thcsc thoughts more objcctivcly. Paticnts are ncxt instructcd
in uncovcring cognitivc distortions in thcir thinking (c.g., catastrophiz-
¡ng, mind rcading, all-or-nothing thinking) and cxamining thc evidcncc
supporting and rcfuting anxiogcnic thoughts. Bccausc individuáis with
GAD are likcly to undercstimatc thcir ability Co cope in situations, and to
overcstimatc both thc potcntial for ncgativc cvcnts to occur and thc ncga-
tivc consequcnccs rclatcd to thesc evcnts, probability estimation tcchniqucs
are taught to allow paticnts to mcasurc thc actual likclihood of thcsc evcnts
more accurately. Paticnts are also taught to genérate aitcrnativc cxplana-
tions and rational rcsponscs that challenge distortcd anxiogcnic thoughts
(c.g., "My son clid not cali me bccausc he lose crack of time" instcad of
"My son did not cali me bccausc he muse havc had an accidcnt"). Finally,
paticnts are taught problcm-solving tcchniqucs so that thcy can be proac-
tivc about gcncrating and implcmcnting solutions to thcir problcms.
A sccond basic CBT stratcgy is rclaxation training. Rcduction in au-
tonomic arousal has bccn targctcd with a varicty of relaxation stratcgics,
ranging from progrcssivc musclc rclaxation to biofecdback-assisced procc-
clurcs (Barlow ct al., 1984; Cragan Si Dcffcnbachcr, 1984; Townscnd,
Housc, & Addario, 1975). Progrcssivc muscic rclaxation is probably thc
most commonly cmploycd stratcgy; it consists of having paticnts Icarn to
systematically rclax progrcssivcly largcr groups of musclcs until thcy can
ultimatcly relax all thc musclcs at once by using a single cucd word likc
"rclax" or "calm." This type of rclaxation is oftcn initially taught in trcat-
mcnt sessions and then assigncd as a homcwork accivity with a casscccc
M
188 ANX/ETY D1SOKDERS
tape. Mcrcly giving patients a tape without dcmonstrating thesc techniques
has been associatcd with less than optimal trcatment outcome (Borkovec
&. Sidcs, 1979). Paticnts are encouragcd to apply thcir relaxation skills
when they are engaged in worry and cxpcricncing physical symptoms of
anxiety. Research has suggestcd that progressivc musclc rclaxation is lielpful
to patients with GAD, but it should be implcmented carly in trcatment,
because it often takes 4-8 weeks for its bencfits to be rcalizcd by patients
(Craskc et al., 1993).
Many individuáis with GAD attempt to mentally block negativc or
catastrophic images and to distract themselves from such images. As a rcsult,
thc anxiety associatcd with thcsc images ¡s never allowed to habitúate.
Worry cxposure is a CDT procedure dcveloped specifically to countcract
this problcm; it involvcs having patients focus on frightcning or catas-
trophic imagcs (c.g., "I will lose my Job and be living on thc strcct") íor
discreto pcriods of time, usually bctwccn 25 and 50 minutes. Patients are
instructed to try to make thc images as vivid and anxicty-provoking as
possiblc. Because of their habitual tcndcncy toward distraction and
avotdance, patients may at first havc clifficulty staying focuscd on thc trn-
ages; it is thcrcforc oftcn hclpful initially to complete exposurcs in a trcat-
ment session, and thcn later to assign them as homework. It may be hclpful
for patients to makc "subjective units of distrcss" ratings of their anxiety
at 5-minute intcrvals during the exposures, in order to have a more tangi-
ble measure of whethcr their anxiety is dccreasing. Thcsc ratings are madc
on a scale of O to 100, with 100 rcflccting extreme anxiety and O rcflcct-
ing no anxiety at al!.
Somc patients may find that sclf-directcd trcatmcnts, such as bibliother-
apy, are helpful adjuncts to individual thcrapy. Some matcrials are also
dcsigned to be uscd by motivatcd patients indcpcnclcntly of professionals.
Thc advantages to sclf-dircctcd trcatmcnts includc dccrcased cost, incrcascd
disscmination, and decrcascd stigmatization. Sclf-dircctcd trcatmcnts vary
from general inspirational works (c.g., Ross, 1994b) to spccific forms of
CBT with cxplicit homework cxcrcises (e.g., Craskc ct al., 1993).
Trcatment Outcome Findings
Outcome for Formj of CBT
How cffective are standard CBT techniques in terms of cmpirical trcat-
ment outcome? In general, results have been promising. Treatmcnt out-
come studics havc varicd in their dcsign, comparing CBT to no-trcatment
or waiting-list controls, to relaxation alone, to pill placebo conditions,
and to standard pharmacothcrapy trcatmcnts. A number of studics have
found that CBT trcatments are superior to no-treatmcnt and waiting-list
control conditions in the short tcrm (less than 6 months) (Woodward &
Jones, 1980; Barlow et al., 1984; Blowers, Cobb, & Mathcws, 1987; But-
ler, Cullington, Hibbcrt, Klimcs, ók Gcldcr, 1987; Butlcr, Fcnnell, Rob-
C»íii¡(iiv-Dc/iíivi«r«/ Trcfllmcní u¡ Sixr/al Plutbía and GAD 189
son, &. Gcldcr, 1991; Lindsay, Gamsu, McLaughlin, Hood, & Espié, 1987;
Barlow, Rapcc, & Brown, 1992). Some studies havc employcd a technique
called "anxiety management training" (Suinn ók Richardson, 1971), in
which anxiety symptoms are clicitcd in the thcrapy office and the paticnt
etnploys applicd relaxation tcchniqucs to cope wirh thcm. Two studics
have found thcsc tcchniqucs to be superior to a no-treatmcnt control (Jan-
noun, Oppcnhcimcr, &. Geldcr, 1982; Tarricr &. Main, 1986).
Research comparing CBT techniques to medication intcrventions have
found gcncrally that CBT ¡s cquivalcnt or superior to mcdications. Lind-
say et al. (1987) found greatcr initial gains in patients rccciving the bcn-
zodiazcpinc lorazepam, but no differcnces between thcsc subjects and
subjccts rcceiving CBT at 4 wccks. In addition, because of thc lack of
sustaincd ¡mpmvcmcnt among lorazcpam-trcatcd subjccts, over half of thcm
rcfuscd to wuit without trcatment until thc follow-up asscssmcnt. A study
comparing the effectivcncss of diazcpam to CBT intcrventions found that
CBT was superior at posttrcatment, and that subjects receiving this treat-
incnt wcrc less likely to havc uscd subscqucnt psychotropic medications
or pursuccl othcr psychologic trcatmcnts at a 12-month follow-up (Power
et al., 1989). Power and his collcagucs latcr replicatcd this finding and
also found that diazepam was no more cffective than placebo (Power, Simp-
son, Swanson, ck Wallacc, 1990).
Studies dcmonstrating thc supcriority of CBT tcchniqucs to nondirec-
tivc treatment havc bccn mixcd. Blowers et al. (1987) found that an in-
tcrvcntion combining cognitivc therapy with relaxation training was not
significantly bcttcr than nondircctive counseling. Similarly, Borkovec and
Mathews (1988) found no diffcrcnccs bctwccn thrcc trcatment groups that
cmployed progressivc musclc rclaxation training plus cithcr nondircctive
thcrapy, coping dcsensitiíation, or cognitivc thcrapy. This finding
challengcd thc results of an carlicr study by thcsc authors (Borkovcc ct
al., 1987), in which thcy found that cognitivc thcrapy with rclaxation was
superior to nondircctive thcrapy with rclaxation. In general, thesc find-
ings suggcst that at Icast part of thc cffcctivencss of CBT trcatment can
be attributcd to nonspccific trcatment effccts, such as the instillation of
hope, the cxpcctation of ¡mprovcmcnt, and participation in a trcatment
study.
Therc is somcwhat more cvidcncc for thc bcncfit of CBT whcn a retum
to normal functioning ¡s thc outcome critcrion. In a rcvicw of the trcat-
ment litcraturc using this critcrion, Durham and Alian (1993) found that
roughly half (57%) of patients in CBT achicved a rcturn to normal func-
tioning, comparcd to only 22% in relaxation treatment alone. Thcse authors
also rcportcd that psychologic trcatments of GAD in general yiclded a
50% reduction in thc scvcrity of somatic symptoms and a 25% decrease
in mcasurcs of trait anxiety. In addition, thcsc positivo changes were like-
ly to be maintaincd at 6-month follow-up.
There ¡s a paucity of long-tcrm trcatment outcome results for GAD.
Four studics using CBT approachcs havc dcmonstratcd maintenance of
 ¡90 ANX/ETV DISORDERS
trcatment gains over a 3- to 6-month íbllow-up (Lindsay ct al., 1987; Power
et al., 1990; Whitc &. Kccnan, 1990; Butlcr ct al., 1991). Intervcntions
that include cognitivc rcstructuring appcar to providc more stablc long-
term outcome and bcttcr rctcntion in treatment than rclaxation trcatmcnts
alone (Barlow et al., 1992; Butlcr ct al., 1991; Durham ckTurvcy, 1987).
In a rcview of psychosocial trcatmcnts, Durham and Alian (1993) found
an avcrage reduction of 54% in Hamilton Rating Scalc for Anxiety (HAM-
A; Hamilton, 1959) scorcs at thc cnd of treatment and 50% at longcr-
term follow-up asscssmcnts. Thc tcndcncy to worry was itsclf rcduccd by
25%. ' '
Pharmacologic and Combined Teclmiques
The class of drugs long associatcd with anxiety relicf has been thc ben-
zodiaicpines, and rcsults on thcir cfficacy for trcating GAD havc becn
gcncrally favorable. A numbcrof studics havc found that bcnzodiazcpincs
are superior to pill placebo controls (Ansscau, Doumont, Thiry, von Frcnck-
cll, &. Collard, 1985; Cohn, Rickcls, &. Stccgc, 1989; Rickcls ct al., 1982).
Roughly 35% of paticnts with GAD trcatcd with bcnzodiazcpincs show
markcd ¡mprovcmcnt, and 40% demónstrate modérate improvcmcnt but
are still symptomatic (Uhlcnhuth, Dcwitt, Baltcr, Johanson, &. Mcllingcr,
1988). Tablc 7.2 prcscnts data comparing psychosocial and bcnzodiaze-
pinc trcatmcnt for GAD. In a rcview of ninc studies of bcnzodiazcpinc
trcatmcnt of GAD, Barlow (1988) found an avcrage reduction in HAM-
A scorcs of 48%. By way of comparison, placebo trcatment was associatcd
with an avcrage 30% reduction in thcsc scorcs. Henee, likc thc rcsults
from CBT studics, thcsc rcsults suggcst thc difficultics of obtaining an out-
come through active trcatmcnt that significantly cxcccds nonspccific or
placebo trcatmcnt cffccts.
Although bcnzodiazcpincs havc dcmonstratcd thcir cffcctivcncss in
providing symptomatic relicf for GAD paticnts, a numbcr of drawbacks
have becn citcd; thcsc include sidc cffccts (c.g., impaircd cognitivc per-
formance, lethargy), drug tolcrancc, drug dcpendcncc, and relapsc upon
withdrawal (Shadcr &. Grecnblatt, 1993). Dubovsky (1990) has rcportcd
TABLE 7.2. Mean Pcrccntagc Ucduction in Hamilton Raling Scalc
for Anxiety (HAM-A) Scorcs in Studics of I'aticnls with GAO
Pcrccntage reduction in scorcs
Trcatmcnt Mean Rangc
Psychosocial trcatmcnf 50% 20-76%
Bcruodlaicpinc trcatmcnt'' 48% 22-62%
Placebo trcatmcnt'' 30% 18-48%
'Data (rom Durham and Alian (199)).
'Dará frnm líarlnw (1988).
C<i£iii(¡vi"Dcíuivnir<il Trcalmcm uf Social Pluilria and GAD 191
a relapsc to basclinc symptoms in 63-81% of individuáis who discontinué
thcir bcnzodiazcpinc mcdications. Buspironc, an azapironc anxiolytic agcnt,
has thc advantagcs of fcwcr scdativc side cffects and Icss potencial for re-
bound anxiety upon withdrawal. Thc limitcd research on trcatmcnt cf-
fcctivencss with buspironc suggcsts that it may be as uscful as
bcnzodiazcpincs (Cohn ct al., 1989; Fcighncr &. Cohn, 1989; Sussman,
1987).
Only onc study in thc GAD treatment litcraturc combincd psycho-
logic and phannacologic trcatmcnt stratcgics. Power ct al. (1990) found
that CBT plus diazcpam was no bcttcr than CBT alone, but that both
of thcsc trcatmcnts wcrc superior to diazcpam alone. Futurc outcome
research should furthcr invcstigate thc cfficacy of combincd trcatmcnts.
Mcla-Analyíic Fmclings
Somc rcscarchcrs havc uscd mcta-analytic tcchniqucs to asscss diffcrcnccs
in trcatmcnt outcome more objcctivcly. Chamblcss and Gillis (1993) rcport-
cd a largc within-group prc-to-post cffcct sizc (1.69) for CBT in scvcn GAD
studics; thcsc trcatmcnt gains wcrc maintaincd at 6- and 12-month follow-
ups. By comparison, thc effcct sizc for control groups that werc uscd in
some of thcsc studics was considcrably smallcr (0.60). Hunt and Singh (1991)
also uscd mcta-analytic tcchniqucs to evalúate trcatmcnt outcome in 42
studics. Rcsults bascd on short-tcrm outcome indicatcd that on mcasurcs
of anxiety, short- and long-acting bcnzodiazcpincs and buspironc wcrc all
roughly equivalcnt. All thrcc drugs wcrc superior to drug placebo condi-
tions. CBT that includcd cognitivc rcstructuring and rclaxation training
wcrc cquivalcnt to drug intcrvcntions and superior to waiting-list controls.
In addition, CBT intcrvcntions had bcttcr long-tcrm rcsults than did drug
thcrapics. Finally, rclaxation tcchniqucs alone wcrc not as cffcctivc as drug
or CBT intcrvcntions and wcrc not diffcrcnt from waiting-list controls.
Hunt and Singh havc cndorscd CBT as thc trcatmcnt of choicc bccausc
of its short- and long-tcrm bcncfits.
In a more reccnt mcta-analysis Gould ct al. (1995) comparcd CBT
to pharmacothcrapy in 27 studics that cmploycd a control comparison con-
dition. Stibjccts ¡n thcsc studics wcre rcquircd to mcct DSM (111, 111-R,
or IV) criteria for GAD, or would havc met thcsc critcria had thcy becn
applicd. Effect sizcs for anxiety wcrc calculatcd only from validatcd sclf-
rcport qucstionnaircs and clinician-ratcd mcasurcs, Pharmacothcrapy studics
(n = 15) yicldcd an acutc (Icss than 6 months) mean cffcct sizc of 0.57
rclativc to placebo and subjccts droppcd out at thc rate of 15.4%. Bcn-
zodiazcpincs wcrc thc drug most commonly cmploycd for GAD trcatmcnt
(n = 11 studics) and thcir mean cffcct sizc was 0.67; howcvcr, scvcral
authors rcported difficultics with tapcring thcsc agcnts and relapsc upon
tapcr. Buspironc was cmploycd in 6 studies and its mean effcct sizc was
0.44. Thrcc controllcd studics asscssed thc efficacy of antidcprcssants and
thcir mean cffcct sizc was 0.57.
 192 ANXIETY DISORDERS
Cognitive-behavioral intervcntions ¡ncluded studies that utilizad cog-
nitivc restructuring, relaxation training, exposure, anxicty managcment
training, or combinations of these. A total of 14 studies used CBT without
pharmacotherapy , and their mean anxiety effcct sizc vvas 0.7 1 . The mean
dropout rate for CBT intcrventions in thcsc studies was 1 1.6%. In gener-
al, therc were no significant differenccs between subtypes of CBT inter-
vcntions, and all were superior to the nuil hypothesis (effcct size = 0.0).
Interventions that uscd both cognitivc and behavioral techniques yicldcd
strong effect sizes (0.90) as did Anxiety Management Training (0.74). Puré
cogntive therapy (0.59) and relaxation training (0.63) appcarcd to be cf-
fective interventions. Studies cmploying behavioral techniques alone ap-
pearcd to be least cffcctivc (0.48).
Comparisons of studies utilizing cognitivc-behavioral trcatments (0.7 1)
to those using pharmacotherapy (0.57) were not statistically significant.
In addition, mean attrition rates were not significantly diffcrent between
the two forms of treatment. Only onc study (Power ct al., 1990) attempt-
ed to combine CBT and medication, and results from this study were
promising.
In summary, the availablc data suggcst that CBT and bcnzodiazcpinc
treatment for GAD are both cffective in the short tcrrn; howcver, problctns
with drug side effects and tolerancc make benzodiazepines a less attrac-
tive first-line intervcntion. Treatment gains appcar to be better maintaincd
over long follow-up periods (1 to 2 years) with CBT. CBT is also associat-
ed with decrcased concomitant medication use ovcr follow-up periods
(Barlow et al., 1992; Hunt ók Singh, 1991; White, Kccnan, ck Brooks,
1991).
Treatmcnt Resistance/Maximizing Treatment Effccttvcncss
A number of patients with GAD may respond only modestly to standard
CBT strategies (Barlow et al., 1992). Unfortunately, rescarch on GAD
is less advanced than that on othcr anxicty disordcrs, and data indicating
clinical predictors of treatment rcsponsc are not abundant. Some authors
have reported that comorbid depression in GAD patients is a predictor
of suboptimal treatment outcome and is positivcly corrclatcd with the chro-
nicity and severity of anxicty symptoms (Breslau & Davis, 1985; Butler
et al., 1987). This finding is particularly troubling, givcn the fact that onc-
third to one-half of GAD patients prcsenting for treatment suffcr from
comorbid depression or dysthymia (de Ruiter, Rijkcn, Garssen, van Schaik,
ck Kraaimaat, 1989; Butler ct al., 1987). For GAD patients rcceivingCBT,
comorbid depression can be particularly problcmatic bccausc of the num-
ber and varicty of homework tasks (c.g., practicing rclaxation techniques,
completing thought records) that are esscntial to this intervcntion. Sevcral
strategies that wc have suggested in Chapter 5 of this volume for treating
comorbid panic disorder and depression may also be useful for hclping GAD
patients with comorbid depression. These include (1) educating patients
Cogiúlive-Behaviinal Traumciu iif Suciiil Phubia and CAD 193
about the cognitivc biases that accompany dcprcssion; (2) having patients
monitor these biases and apply cognitivc restructuring skills that targct
thcm; and (3) devoting extra time in scssions to encouraging compliance
with homework assignmcnts. CBT for GAD alone may help to reduce
deprcssive symptomatology (Chambless ck Gillis, 1993). In patients with
more scverc depression, a standard trial of CBT for dcprcssion or use of
antidepressant medication may be neccssary prior to GAD treatment.
Patients with GAD may also present with comorbid panic disorder,
social phobia, and alcohol abuse (Barlow, 1988; Tyrer, 1984). Butler ct
al. (1987) reported that 29% of thcir GAD study samplc suffercd from panic
disorder. Similarly, Jannoun et al. (1982) reported that one-third of their
samplc suffcred from comorbid agoraphobia. For patients with comorbid
panic disorder whosc main focus of worry is having a panic attack, a stan-
dard course of CBT for panic prior to GAD treatment may be most help-
ful. For patients having panic disordcr with mild agoraphobia, we find that
an carly introduction to brcathing retraining skills, along with interocep-
tivc cxposure cxcrcises, can cnhancc GAD treatment. In many ¡nstances,
sclf-help books about panic disordcr and agoraphobia (e.g, Clum, 1990;
Barlow &. Craskc, 1993) may be cmploycd concurrcntly with GAD treat-
ment. For patients with comorbid social phobia, extra scssions may need
to be dcvotcd to cognitivc restructuring training that teaches them how
to challenge and change thoughts associatcd with fcar of negativc evalua-
tion. In addition, in vivo homework assignmcnts rcquiring systcmatic ex-
posure to fearcd sociíil situations may be beneficial.
Whcn standard CBT techniques for GAD are not succcssful, patients
may bcncfit from treatment strategies appropriate for more sevcrely ob-
scssional conditions. Somc patients rcport that thcy try to push these ob-
sessive worries away by using distraction techniques, but find that this
strategy is only helpful in the short tcrni. For patients with obsessive-com-
pulsivc disorder charactcrized by primary obscssional symptoms, bencfits
have becn reported for cxposure strategies utilizing a loop tape, which al-
lows patients to listen to thcir obsessivc thoughts repeatcdly in an exposure
format (Salkovskis, 1983;Thyer, 1985), With repcated exposure, the ten-
dcncy to respond to these thoughts with anxicty or rituals is broken.
An additional aspcct of treatment that may influcnce longer-term out-
come is relapse prevcntion training. CBT intcrvcntions for anxiety gcncrally
include instruction in the naturc of the disorder and cncouragemcnt of
paticnts to Icarn ncw rcsponses to anxicty with cognitive restructuring
and cxposure excrciscs. Paticnts are instructcd to apply this new Icarning
to situations ¡n their own lives, and this learning is designcd to continué
to occur aftcr the complction of formal treatment. In all of our anxiety
treatment programs, we cncouragc patients to continué to practice somatic
symptom managcment skills {e.g., rclaxation) and cognitivc restructuring
and cxposure tcchniques after the short-term CBT intervcntion. Patients
are also instructed in a model of relapsc prcvention that stresses the reap-
plication of treatment procedures whcn high-risk situations are encoun-
 ANXIETV DISORDERS
tercd and/or if symptoms rcturn. Such proccdurcs havc been shown to be
hclpful at ¡mproving long-tcrm outcomc (Óst, 1987).
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