Mediated moderation in combined cognitive behavioral therapy versus component treatments for generalized anxiety disorder.
Open accessAbstract
OBJECTIVE: This study examined (a) duration of generalized anxiety disorder (GAD) as a moderator of cognitive behavioral therapy (CBT) versus its components (cognitive therapy and self-control desensitization) and (b) increases in dynamic flexibility of anxious symptoms during the course of psychotherapy as a mediator of this moderation. Degree of dynamic flexibility in daily symptoms was quantified as the inverse of spectral power due to daily to intradaily oscillations in four-times-daily diary data (Fisher, Newman, & Molenaar, 2011). METHOD: This was a secondary analysis of the data of Borkovec, Newman, Pincus, and Lytle (2002). Seventy-six participants with a principle diagnosis of GAD were assigned randomly to combined CBT (n = 24), cognitive therapy (n = 25), or self-control desensitization (n = 27). RESULTS: Duration of GAD moderated outcome such that those with longer duration showed greater reliable change from component treatments than they showed from CBT, whereas those with shorter duration fared better in response to CBT. Decreasing predictability in daily and intradaily oscillations of anxiety symptoms during therapy reflected less rigidity and more flexible responding. Increases in flexibility over the course of therapy fully mediated the moderating effect of GAD duration on condition, indicating a mediated moderation process. CONCLUSIONS: Individuals with longer duration of GAD may respond better to more focused treatments, whereas those with shorter duration of GAD may respond better to a treatment that offers more coping strategies. Importantly, the mechanism by which this moderation occurs appears to be the establishment of flexible responding during treatment.
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CBT, cognitive therapy, and self-control desensitization may enhance flexibility during treatment, which in turn results in more reliable posttreatment reduction of generalized anxiety disorder symptoms.
“CBT, CT, and SCD may also enhance flexibility during treatment (i.e., patients’ level of responding to changes in their environment), which in turn resulted in more reliable change at posttreatment in the reduction of GAD symptoms [34].”
From Psychotherapeutic treatments for generalized anxiety disorder: cognitive and behavioral therapies, enhancement strategies, and emerging efforts (2022) · cites this paper as [34]
The Results (Nomothetic Analyses; page unavailable) report that greater increases in flexibility predicted greater reliable change at posttreatment. The claim omits a key condition: among patients with longer-duration GAD, flexibility and reliable change increased in CT and SCD but decreased in combined CBT. (LLM, conf=0.84)
Experimental — accuracy not yet measuredPeople with longer-duration generalized anxiety disorder benefit more from a component treatment such as cognitive therapy or self-control desensitization than from combined CBT, while the opposite holds for shorter-duration generalized anxiety disorder.
“those with longer duration of GAD benefitted more from a component treatment, CT or SCD, than from combined CBT, whereas the opposite was true for those with shorter duration GAD [34,35].”
From Psychotherapeutic treatments for generalized anxiety disorder: cognitive and behavioral therapies, enhancement strategies, and emerging efforts (2022) · cites this paper as [34]
Mediators of CBT include the establishment of flexible emotional responding and change in expectancy or credibility.
“mediators of CBT have included the establishment of flexible emotional responding [34] and change in expectancy/credibility [37].”
From Psychotherapeutic treatments for generalized anxiety disorder: cognitive and behavioral therapies, enhancement strategies, and emerging efforts (2022) · cites this paper as [34]
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- Newman MG Borkovec TD Simos G Cognitive behavioral therapy for worry and generalized anxiety disorder Cognitive behaviour therapy: A guide for the practising clinician 2002 New York, NY Taylor & Francis 150 172
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“…12 of 56 Ac ce pt ed M an us cr ip t 11 (Hoehn-Saric et al., 2004)* 40 0% 24 26 Healthy Panic disorder Paper Time 12 4 48 (Newman, Consoli, & Taylor, 1999) 3 67% - - PDA Time 5 16 82 2 442 (Newman & Fisher, 2013) 67 c 3% - - Paper Time 4 140 560 Social phobia (Faytout & Swendsen, 2009) 40 ?”
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“Such emotional rigidity has also been demonstrated in diary studies of people with GAD (Newman & Fisher, 2013).”
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“Newman and Fisher (2013) found that increases in the flexibility of anxiety levels during a clinical trial comparing CBT to its component parts mediated the effect of all treatments on outcome.”
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“There are four possible factors that lead to this unexpected result: (a) the number of studies and number of cases was smaller for the CBT versus PP comparison to those for the CBT versus WL comparison, resulting in reduced power to identify differences; (b) the use of the dichotomous secondary outcome measure is much…”
ResultZainal, N. H., & Newman, M. G. (2017) · Journal of Affective Disorders · doi:10.1016/j.jad.2017.11.084 · Cited by 54 · see citing works
“, exposure therapy, relaxation training, cognitive restructuring) may inquire on whether substantial reductions in negative-reasoning ToM functions as a treatment mechanism in cognitivebehavioral (Newman and Fisher, 2013) and interpersonally-oriented therapies for GAD (Newman et al.”
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“Although studies are beginning to emerge on this topic, there has been limited research with respect to cognitive behavioral therapy (CBT) for generalized anxiety disorder (GAD; Newman, Castonguay, Jacobson, & Moore, 2015; Newman & Fisher, 2013).”
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“Exploratory analyses of RT in the subset of subjects with complete RT data for every condition ( N =15; High‐BI: n =5/11; Low‐BI: n =10/12) were broadly consistent with prior work using unselected samples of laboratory‐raised monkeys 8, 21, 22 .”
BackgroundResultNewman, M. G., Kanuri, N., Rackoff, G. N., Jacobson, N. C., Bell, M. J., & Taylor, C. B. (2021) · Psychotherapy · doi:10.1037/pst0000383 · Cited by 34 · see citing works
“Of note, research on psychotherapy for GAD has indicated that, for some people, repeated practice of fewer skills generates greater symptom reduction than instruction in a broad variety of techniques (Newman & Fisher, 2013; Newman et al., 2019).”
BackgroundSelf-citationExposing Worry’s Deceit: Percentage of Untrue Worries in Generalized Anxiety Disorder Treatment
LaFreniere, L. S., & Newman, M. G. (2020) · Behavior Therapy · doi:10.1016/j.beth.2019.07.003 · Cited by 35 · see citing works
Self-citationFisher, A. J., & Newman, M. G. (2016) · Behaviour Research and Therapy · doi:10.1016/j.brat.2016.02.006 · Cited by 29 · see citing works
“…rigidity, and stability are popular constructs that have been employed across various psychological research domains, including psychotherapy (Newman & Fisher, 2013), psychophysiology (Fisher & Woodward, 2014; Hoehn-Saric, McLeod, Funderburk, & Kowalski, 2004), personality (Wright, Pincus, &…”
MethodSelf-citationNewman, M. G., Basterfield, C., Erickson, T. M., Caulley, E., Przeworski, A., & Llera, S. J. (2022) · Expert Review of Neurotherapeutics · doi:10.1080/14737175.2022.2125800 · Cited by 27 · see citing works
“Lastly, mediators of CBT have included the establishment of flexible emotional responding [34] and change in expectancy/credibility [37].”
Self-citationExposure Therapy for Anxiety Disorders
Steinman, S. A., Wootton, B. M., & Tolin, D. F. (2016) · Encyclopedia of Mental Health · doi:10.1016/b978-0-12-397045-9.00266-4 · Cited by 27 · see citing works
Cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD)
Newman, M. G., Zainal, N. H., & Hoyer, J. (2020) · Generalized Anxiety Disorder and Worrying · doi:10.1002/9781119189909.ch10 · Cited by 25 · see citing works
Self-citationDevelopment of a video-delivered relaxation treatment of late-life anxiety for veterans
Gould, C. E., Zapata, A. M. L., Bruce, J., Bereknyei Merrell, S., Wetherell, J. L., O'Hara, R., Kuhn, E., Goldstein, M. K., & Beaudreau, S. A. (2017) · International Psychogeriatrics · doi:10.1017/s1041610217000928 · Cited by 23 · see citing works
“The leading non-pharmacological treatment, Cognitive Behavioral Therapy (CBT), has been tested in many studies of late-life anxiety, predominantly focused on generalized anxiety disorder (GAD).”
ResultInfluentialNewman, M. G., Lafreniere, L. S., & Jacobson, N. C. (2018) · Psychotherapy Research · doi:10.1080/10503307.2016.1253891 · Cited by 21 · see citing works
“In addition, convergent and discriminant validity was demonstrated by significantly stronger correlations with the Hamilton Anxiety Scale than with the Hamilton Depression Scale (Newman & Fisher, 2013).”
Self-citationWithin-day sudden gains and generalized anxiety disorder psychotherapy outcome.
Newman, M. G., Schwob, J. T., & Rackoff, G. N. (2022) · Psychotherapy · doi:10.1037/pst0000445 · Cited by 19 · see citing works
Self-citationFuture Directions for the Examination of Mediators of Treatment Outcomes in Youth
Carper, M. M., Makover, H. B., & Kendall, P. C. (2017) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2017.1359786 · Cited by 18 · see citing works
“The authors concluded that individuals who have had GAD for a longer duration may respond better to more focused treatment and that the mechanism by which this moderation occurs is through the establishment of flexible responding during treatment (Newman & Fisher, 2013).”
BackgroundA theoretical and empirical modeling of anxiety integrated with RDoC and temporal dynamics
Frank, B. E., Jacobson, N. C., Hurley, L., & McKay, D. (2017) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2017.09.002 · Cited by 16 · see citing works
Worry and Generalized Anxiety Disorder: A Review
Newman, M. G., Cho, S., & Kim, H. (2016) · Elsevier eBooks · doi:10.1016/b978-0-12-809324-5.05108-7 · Cited by 31 · see citing works
“Although worry is employed as a strategy to avoid the contrast experience, it inadvertently perpetuates dysfunctional interpersonal processes which may further maintain and exacerbate the symptoms of GAD (Erickson et al., 2016; Newman and Fisher, 2013; Newman and Erickson, 2010).”
BackgroundMethodResultInfluentialSelf-citationNewman, M. G., Shin, K. E., & Lanza, S. T. (2019) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000385 · Cited by 12 · see citing works
“At the same time, it is possible that mechanisms of change related to GAD duration might not be specific to the type of skills taught in AR. Newman and Fisher (2013) found that compared with CBT, self-reported duration of GAD also predicted better outcomes from other single-component interventions…”
BackgroundResultInfluentialSelf-citationCohen, J. N., Drabick, D. A. G., Blanco, C., Schneier, F. R., Liebowitz, M. R., & Heimberg, R. G. (2017) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2017.10.004 · Cited by 12 · see citing works
Nojoumi, M., Ghaeli, P., Salimi, S., Sharifi, A., & Raisi, F. (2016) · Europe PMC (PubMed Central) · Cited by 11 · see citing works
The impact of cognitive training on spontaneous gamma oscillations in schizophrenia
Popova, P., Rockstroh, B. S., Miller, G. A., Wienbruch, C., Carolus, A. M., & Popov, T. G. (2018) · Psychophysiology · doi:10.1111/psyp.13083 · Cited by 10 · see citing works
Rosen, F. N., & LaFreniere, L. S. (2023) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2023.102724 · Cited by 7 · see citing works
The effects of worry proneness on diurnal anxiety: An ecological momentary assessment approach
Cox, R. C., Jessup, S. C., & Olatunji, B. O. (2022) · Personality and Individual Differences · doi:10.1016/j.paid.2022.111529 · Cited by 5 · see citing works
Malivoire, B. L., Stewart, K. E., Cameron, D., Rowa, K., & McCabe, R. E. (2024) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465823000632 · Cited by 4 · see citing works
“In a study that investigated duration of GAD symptoms as a moderator of outcome for CBT and its components, those who had suffered from GAD longer were found to have better outcomes for CBT components specifically (i.e. cognitive therapy and self-control desensitization; Newman and Fisher, 2013).”
Stańko-Kaczmarek, M., Jankowski, T., Bartel, R., Stankowska, M., Andrzejewska, M., Rybakowski, F., Kaczmarek, L. D., & RYBAKOWSKI, J. K. (2025) · Journal of Happiness Studies · doi:10.1007/s10902-025-00932-1 · Cited by 4 · see citing works
“Our observation aligns with other studies showing that emotional variability decreases during therapy (e.g. Newman & Fisher, 2013) and is also predicted by the Damped Oscillator Model of Emotions formulated by Chow et al. (2005).”
Changes in Affective Network Variability Among Youth Treated for Anxiety Disorders
Carper, M. M., Silk, J. S., Ladouceur, C. D., Forbes, E. E., McMakin, D. L., Ryan, N. D., & Kendall, P. C. (2021) · Child Psychiatry & Human Development · doi:10.1007/s10578-021-01141-6 · Cited by 3 · see citing works
Metacognitive, Emotional, and Avoidance Predictors of Generalized Anxiety Disorder
Sugiura, Y. (2017) · Psychology · doi:10.4236/psych.2017.84041 · Cited by 4 · see citing works
“Recent evidence indicates that the chronicity of GAD affects whether a focused single intervention or multi-faceted intervention is superior (Newman & Fisher, 2013).”
BackgroundGeneralized Anxiety Disorder: Diagnosis and Treatment
Soen, C. C., Hardjasasmita, I. M., & Ulitua, A. E. (2022) · Jurnal Muara Medika dan Psikologi Klinis · doi:10.24912/jmmpk.v1i2.14865 · Cited by 3 · see citing works
Mechanisms and Treatment of Generalized Anxiety Disorder
Newman, M. G., Shin, K., & LaFreniere, L. S. (2017) · Wiley eBooks · doi:10.1002/9781118877142.ch8 · Cited by 3 · see citing works
Self-citationBilgi çağının yeni trendi: Dijital istifçilik üzerine bir araştırma
DEMİRTAŞ, M., & KOÇ, N. E. (2022) · RumeliDE Dil ve Edebiyat Araştırmaları Dergisi :/RumeliDe Dil ve Edebiyat Araştırmaları Dergisi · doi:10.29000/rumelide.1132565 · Cited by 2 · see citing works
The therapygenetics of anxiety disorders
Vashishtha, S., Kloiber, S. M., & Zai, G. C. (2023) · Psychiatric Genetics · doi:10.1097/ypg.0000000000000342 · Cited by 2 · see citing works
Baik, S. Y., & Newman, M. G. (2023) · Elsevier eBooks · doi:10.1016/b978-0-323-91497-0.00264-2 · Cited by 2 · see citing works
Self-citationSchwob, J. T., & Newman, M. G. (2026) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2026.103160 · Cited by 1 · see citing works
Self-citationAlladin, A. (2015) · Wiley eBooks · doi:10.1002/9781118509869.refs
Carving Out the Path to Computational Biomarkers for Mental Disorders
Sladky, R., Todeva-Radneva, A., & Lamm, C. (2023) · Neuromethods · doi:10.1007/978-1-0716-3230-7_10
Bandeira, K. V. D. S., Machado, L. P., Reis, A. F., Martins, H. M. R. L., Antero, J. H. B. D., Menezes, C. W. C., Cunha, A. C. L., Araújo, L. P. L., & de Oliveira, S. A. S. (2024) · Revista Ibero-Americana de Humanidades, Ciências e Educação · doi:10.51891/rease.v10i9.15515
Initial effectiveness of an ICBT-protocol for GAD in psychiatric care – A feasibility-pilot study
Huhn, V., Andersson, E., Wahlund, T., & Forsell, E. (2025) · Internet Interventions · doi:10.1016/j.invent.2025.100817
“However, while the core symptom of worry is not specific to GAD, there are multiple lines of argument in support of GAD as a stand-alone disorder (Newman et al., 2013).”
- Authors
- Newman, M. G., & Fisher, A. J.
- Affiliations
- Pennsylvania State University (US)
- Venue
- Journal of Consulting and Clinical Psychology
- Published
- 2013
- Volume
- 81
- Issue
- 3
- Pages
- 405-414
- ISSN
- 0022-006X (ISSN-L)
- 1939-2117
- PMC
- PMC4432847
- OpenAlex
- W3123556151
- Cited by
- 45
- References
- 52
- Citations by year
- 2026: 1 · 2025: 2 · 2024: 2 · 2023: 4 · 2022: 5 · 2021: 2 · 2020: 1 · 2019: 3 · 2018: 1 · 2017: 8 · 2016: 6 · 2015: 5 · 2014: 3 · 2013: 2
- FWCI
- 7.15
- Type
- journal article
- Language
- en
- Open access
- green
- doi.org
- Locations
- Journal of Consulting and Clinical Psychology (publishedVersion)
- SSRN Electronic Journal (acceptedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- ScholarSphere (Penn State Libraries) (submittedVersion, cc-by)
- Funders
- National Institute of Mental Health (R01 MH-309172-01)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Keywords
- generalized anxiety disorder, cognitive behavioral therapy, cognitive therapy, treatment duration, dynamic flexibility, anxiety symptoms, mediated moderation, treatment response, coping strategies
- MeSH terms
- Adaptation, Psychological, Adult, Anxiety Disorders, Desensitization, Psychologic, Female, Humans, Male, Middle Aged, Severity of Illness Index, Time Factors, Cognitive Behavioral Therapy, Treatment Outcome
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