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Cited by 27Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesDigital Mental Health InterventionsChild and Adolescent Psychosocial and Emotional Development

Psychotherapeutic treatments for generalized anxiety disorder: cognitive and behavioral therapies, enhancement strategies, and emerging efforts

Open access
Newman, Michelle G., Basterfield, Candice, Erickson, Thane M., Caulley, Evan, Przeworski, Amy, Llera, Sandra J.·2022·Expert Review of Neurotherapeutics
DOI 10.1080/14737175.2022.2125800PMC PMC9754763
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Abstract

Introduction: Generalized anxiety disorder (GAD) is common and disabling. Different versions of cognitive behavioral therapy (CBT) have been tested, but no treatment works for everyone. Therefore, researchers have attempted approaches to enhance CBT. Areas covered: The current narrative review examines meta-analyses and individual trials of CBT-based treatments for GAD. We focus on CBT and its cognitive and behavioral components as well as efforts to enhance CBT and its dissemination and generalizability. Enhancement efforts included interpersonal and emotional processing therapy, mindfulness-based CBT, emotion regulation therapy, intolerance of uncertainty therapy, the unified protocol, metacognitive therapy, motivational interviewing, and contrast avoidance targeted treatment. Emerging strategies to enhance dissemination have focused on technologically based treatments. Attempts at generalizability have included examination of efficacy within diverse racial and ethnic groups. Expert opinion: We conclude that CBT is efficacious, and a number of enhancement efforts have shown some promise in improving upon CBT in single trials. However, more research is needed, particularly efforts to determine which enhancements work best for which individuals and what are the mechanisms of change. Furthermore, few technological interventions have been compared to active treatments. Finally, much more attention needs to be paid to ethnic and racial diversity in randomized controlled trials. © 2022 Informa UK Limited, trading as Taylor & Francis Group.

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Crossref · 10.1080/14737175.2022.2125800

Cites

121 of 121 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

78 of 145 cited sources checked · 45 supported · 2 flagged · accuracy not yet measured

  • Premisecitation

    In that randomized controlled trial, there was a slight increase in residual symptoms at 6-month follow-up.

    “Improvements in clinical severity and general symptoms of anxiety and depression were maintained at 3-month follow-up, with a slight increase in residual symptoms at 6-month follow-up [95].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [95] source

      The Discussion (page unavailable) says patients continued to improve six months after treatment, rather than reporting an increase in residual symptoms. The Results section on clinical significance among treatment initiators likewise reports higher rates of subclinical status and treatment response at follow-up than at posttreatment. (LLM, conf=0.78)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.
  • Findingcitation

    Among remitters, worry exposure is associated with less reduction in reassurance seeking than applied relaxation.

    “in secondary analyses among remitters, worry exposure was associated with less reduction in reassurance seeking relative to AR [26].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
  • Findingcitation

    CBT for generalized anxiety disorder also shows strong efficacy for comorbid anxiety and depressive disorders.

    “CBT for GAD also has shown strong efficacy for comorbid anxiety and depressive disorders [10,12].”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [10] source

      The Results (Efficacy on primary and secondary outcomes; page not provided) report that evidence-based psychotherapies for GAD improved GAD symptoms and secondary depressive symptoms compared with controls. The paper does not establish strong efficacy specifically for CBT in treating comorbid anxiety and depressive disorders: it pools psychotherapies, measures depressive symptoms rather than depressive-disorder outcomes, and does not report treatment effects on other comorbid anxiety disorders. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [12] source

      The Abstract and Discussion report posttreatment reductions in comorbid social phobia, simple phobia, and major depression after cognitive and behavioral therapies for GAD. Calling this strong efficacy for comorbid anxiety and depressive disorders is broader than the findings: the study excluded clinical panic disorder and very severe depression, and depression gains were not maintained at two years. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
  • Premisecitation

    CBT is regarded as a first-line, gold-standard treatment for generalized anxiety disorder.

    “Cognitive behavioral therapies (CBT) are considered first-line, gold-standard treatments for GAD [7].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [7] source

      The Abstract reports large placebo-controlled effects of CBT for GAD, supporting its efficacy. The paper does not say that CBT is considered a first-line or gold-standard treatment for GAD; those treatment-status claims go beyond its findings. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
  • Findingcitation

    Emotion regulation therapy was associated with functional connectivity changes in brain regions associated with emotion and motivation (salience network) and self-referentiality (default mode network), which correlated moderately with symptom improvement.

    “ERT was associated with functional connectivity changes in brain regions associated with emotion/motivation (salience network) and self-referentiality (default mode network), which correlated moderately with symptom improvement [69].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [69] source

      Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured
  • May combine two claims. 62
  • Classified as probably not a substantial claim. 6

  • May combine two claims.

    Findingcitation

    In a meta-analysis of six randomized controlled trials for generalized anxiety disorder symptoms, mindfulness-based interventions had lower post-intervention symptoms than nonactive controls in all studies except one, with g = -0.65 (95% CI -0.97 to -0.32).

    “in one meta-analysis of six randomized controlled trials (RCTs) for GAD symptoms [57], compared with nonactive controls (including no treatment, open trials, education, TAU), MBIs had lower post-intervention symptoms in all studies except one (g = −0.65, 95% CI [−0.97, −0.32]) [58].”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [57] Hedman-Lagerlöf M, 2018, Psychol Med source

      Split into 2 atoms — 0 confirmed, 1 partially supported, 1 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
    • cites [58] source

      Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    Older age, previous psychiatric treatment, being unmarried, and higher peaks in relaxation-induced anxiety predict worse outcomes in generalized anxiety disorder treatment.

    “older age [30,31], having received previous psychiatric treatment [32], being unmarried [32] and higher peaks in relaxation-induced anxiety [33] predicted worse outcomes.”
    Quote in the paperSubstantial claim2 of 4 sources checked
    • cites [30] source
    • cites [31] source
    • cites [32] source
    • cites [33] source

  • May combine two claims.

    Findingcitation

    CBT for generalized anxiety disorder yields greater improvement than treatment as usual, with a reported effect size of g = 0.38 (95% CI 0.05 to 0.71).

    “treatment as usual (TAU; g = 0.38, 95% CI [0.05, 0.71]) [10]”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [10] source

      The Results section (Efficacy on primary and secondary outcomes; page unavailable) reports that evidence-based psychotherapies outperformed treatment as usual on primary GAD outcomes, with g = 0.38 and 95% CI 0.05–0.71. It reports this estimate for psychotherapy comparisons, not specifically for CBT, so the CBT-specific attribution is not established. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    Avoidance strategies do not predict treatment response to worry exposure, but higher cognitive and behavioral avoidance at posttest predicts poorer outcomes at follow-up.

    “avoidance strategies did not predict treatment response to worry exposure, but higher cognitive and behavioral avoidance (e.g., safety behaviors) at posttest predicted poorer outcomes at follow-up [26].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [26] source

      The ‘Behavioral Symptoms as Predictors for Immediate and Long-Term Treatment Outcome’ section (page unavailable) reports that higher posttreatment cognitive and behavioral avoidance predicted worse outcomes at 6- and/or 12-month follow-up. It also reports an exception to the claim about immediate response: higher pretreatment safety behavior predicted a worse posttreatment anxiety score. The predictor findings concern patients receiving either worry exposure or applied relaxation, not worry exposure alone. (LLM, conf=0.86)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    CBT for generalized anxiety disorder yields greater improvement than pill placebo, with a reported effect size of g = 1.44 (95% CI 0.94 to 1.94).

    “A meta-analysis found that CBT for GAD led to greater improvement than pill placebo (g = 1.44, 95% CI [0.94, 1.94])”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [10] source

      The Results section reports greater improvement on primary GAD outcomes in three pill-placebo-controlled psychotherapy comparisons, with g = 1.44 (95% CI 0.94–1.94). It labels this a result for evidence-based psychotherapy, not specifically CBT, so the treatment-specific wording is not established by our copy. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    CBT for generalized anxiety disorder yields greater improvement than psychological placebo, with a reported effect size of g = 0.47 (95% CI 0.25 to 0.69).

    “psychological placebo (g = 0.47, 95% CI [0.25, 0.69])”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [10] source

      The Results (Efficacy on primary and secondary outcomes; page unavailable) report that psychotherapy outperformed psychological placebo on GAD outcomes, with g = 0.47 (95% CI: 0.25–0.69). The Methods (Study selection; page unavailable) include CBT alongside other psychotherapies, so this pooled estimate is not identified as a CBT-specific effect. (LLM, conf=0.90)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    Worry exposure does not differ significantly from applied relaxation, and both are superior to waitlist at posttreatment with maintenance of gains at one-year follow-up.

    “Worry exposure (which also involved encouragement to reduce avoidance and reassurance seeking) was not significantly different from AR; both were superior to waitlist at posttreatment with maintenance of gains at 1-year follow-up [25].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [25] source
      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    People 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].”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [34] source
    • cites [35] source

      Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Study design and conductcitation

    In a randomized controlled trial of CBT plus interpersonal and emotional processing therapy versus CBT plus supportive listening, the groups did not differ on treatment expectancy, credibility, or attrition.

    “The groups did not differ on treatment expectancy, credibility, or attrition.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [51] source

      The Results > Process Measures section reports no significant difference between CBT + I/EP and CBT + supportive listening in treatment expectancy or credibility. Results > Statistical Analyses reports 13 dropouts and a nonsignificant condition-by-dropout interaction for symptom change, but does not establish that attrition rates did not differ between groups. (LLM, conf=0.82)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    Mindfulness-based interventions have efficacy similar to traditional CBT, lower efficacy in clinical than non-clinical samples, and are most efficacious in well-established protocols such as MBSR and MBCT.

    “MBIs had efficacy similar to traditional CBT, but with lower efficacy in clinical than non-clinical samples, and were most efficacious in well-established protocols like MBSR and MBCT [55].”
    Quote in the paperSubstantial claim1 of 1 sources checked

  • May combine two claims.

    Findingcitation

    At follow-up, CBT plus interpersonal and emotional processing therapy was associated with more participants no longer diagnosable with generalized anxiety disorder (75% vs 63.6%) and higher responder status on interpersonal problems (83.9% vs 66.7%), but these differences were not statistically significant.

    “At follow-up, CBT+I/EP was associated with more participants no longer diagnosable with GAD (75% vs. 63.6%) and higher responder status on interpersonal problems (83.9% vs. 66.7%), although these differences were not statistically significant.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [51] source

      Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    Both CBT plus interpersonal and emotional processing therapy and CBT plus supportive listening produced large pre-post improvements in generalized anxiety disorder symptom severity (d = 1.86), depression, and interpersonal problems, with gains maintained at two-year follow-up.

    “Both groups experienced large pre-post improvements for GAD symptom severity (d = 1.86), depression, and interpersonal problems, maintaining gains at two-year follow-up.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [51] source

      Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    Compared with standard CBT and a waiting list, metacognitive therapy led to higher recovery rates than CBT (65% vs 38%) and greater reductions in worry at posttreatment and two-year follow-up.

    “When compared to standard CBT and a waiting list, MCT led to higher recovery rates than CBT (65% recovery versus 38%) and greater reductions in worry at posttreatment and 2-year follow-up [79].”
    Quote in the paperSubstantial claim1 of 1 sources checked

  • May combine two claims.

    Findingcitation

    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].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [34] source

      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 measured

  • May combine two claims.

    Findingcitation

    Nine of 12 papers found greater pre-post reductions in anxiety scores for mindfulness-based interventions than for control groups, with g = 0.57 (95% CI 0.22 to 0.89).

    “Nine of the 12 papers identified greater reductions in pre-post anxiety scores for MBIs compared to control groups (g = 0.57; 95% CI [0.22, 0.89]).”
    Quote in the paperSubstantial claim1 of 1 sources checked

  • May combine two claims.

    Findingcitation

    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].”
    Quote in the paperNot a substantial claim2 of 2 sources checked

  • May combine two claims.

    Findingcitation

    The overall effect size of CBT for generalized anxiety disorder is large for working-age adults (g = 0.94, 95% CI 0.52 to 1.36) but moderate for older people (g = 0.55, 95% CI 0.22 to 0.88).

    “the overall effect size of CBT for GAD was large for adults of working age (g = 0.94, 95% CI 0.52–1.36), but was moderate for older people (g = 0.55, 95% CI 0.22–0.88) [39]”
    Quote in the paperSubstantial claim1 of 1 sources checked

  • May combine two claims.

    Findingcitation

    Acceptance-based behavior therapy for generalized anxiety disorder was tested against applied relaxation; both groups improved at posttreatment and six-month follow-up, with no significant differences between groups.

    “ABBT for GAD, which features mindfulness practices to develop basic skills (e.g., mindfulness of breathing) followed by application to challenging contexts (e.g., observing painful thoughts and emotions during a conflict), was tested against an AR treatment; both groups showed improvement at post and 6-month follow-up, with no significant differences between groups [59].”
    Quote in the paperSubstantial claim1 of 1 sources checked

  • May combine two claims.

    Premisecitation

    The theory suggests that although those with generalized anxiety disorder also worry to increase the probability of a positive emotional contrast, they are uncomfortable with sustained positive or euthymic states because it leaves them vulnerable to a negative emotional contrast.

    “The theory also suggests that although those with GAD also worry to increase the probability of a positive emotional contrast (i.e., greater relief when situations one worried about do not occur), they are uncomfortable with sustained positive or euthymic states because it leaves them vulnerable to a negative emotional contrast.”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [108] source
    • cites [109] source
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisecitation

    Both mindfulness alone and mindfulness plus virtual reality led to reductions in generalized anxiety disorder symptoms, anxiety, and depression.

    “Both groups led to reductions in GAD symptoms, anxiety, and depression (ds ranging −1.27 to −1.36 for Mindfulness; −0.54 to −1.33 for Mindfulness + VR).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisecitation

    A 6-session palmtop computer-assisted group therapy led to a high number of participants achieving change on at least two of three generalized anxiety disorder measures at posttreatment, with no difference compared to a 12-session group therapy without computer (d=0.60).

    “The use of a palmtop computer in addition to six sessions of group therapy led to a high number of participants achieving change on at least two out of three measures of GAD at posttreatment, with no difference when compared to a longer (12-session) group therapy for GAD that did not use the computer (d = .60) [104].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisecitation

    In a recent meta-analysis of 79 randomized controlled trials for various evidence-based psychological and pharmacological treatments for generalized anxiety disorder, older mean age predicted lower treatment efficacy for psychotherapy, but not pharmacotherapy.

    “However, age moderated outcome in a recent meta-analysis [10] of 79 RCTs for various evidence-based psychological (e.g., CBT, acceptance-based behavior therapy, applied relaxation) and pharmacological (e.g., SSRIs, benzodiazepines) treatments for GAD, such that older mean age predicted lower treatment efficacy for psychotherapy, but not pharmacotherapy.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisecitation

    In that study, gains were maintained at 6-month follow-up, but there were no longer differences between conditions in rates of remission (d=-0.23).

    “Gains were maintained at 6-month follow-up; however, there were no longer differences between the two conditions in the rates of remission (d = −0.23).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisecitation

    A higher percent of participants achieved reliable change on at least two of three generalized anxiety disorder measures in the computer-assisted six-session group at all time points than the six-session no-computer group, and a higher percent at 12-month follow-up than the 12-session no-computer group.

    “However, a higher percent of participants achieved reliable change on at least two of the three measures of GAD in the computer-assisted six-session group at all time points than the six-session no-computer group and a higher percent at 12-month follow up than the 12-session no-computer group.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisecitation

    Internet-delivered cognitive behavioral therapy led to significant improvements in generalized anxiety disorder symptoms, pathological worry, comorbid anxiety, depression, distress, disability, and quality of life, with Cohen's d ranging -0.91 to -0.38.

    “Internet CBT (ICBT) led to significant improvements in GAD symptoms, pathological worry, comorbid anxiety, depression, distress, disability, and quality of life, with Cohen’s d ranging between −0.91 to −0.38) [102].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [102] source

      The Results (Meta-analysis of primary and secondary outcomes; page unavailable) report significant benefits for anxiety, worry, depression, functional impairment, and quality of life. They do not separately establish improvements in comorbid anxiety or distress, and the reported effects are Hedges’ g, not Cohen’s d; their values also do not match the claimed −0.91 to −0.38 range. The pooled findings cover Internet-delivered treatments, not ICBT alone. (LLM, conf=0.90)

      Experimental — accuracy not yet measured
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisecitation

    In a study using an ecological momentary intervention called Skilljoy, Skilljoy led to significant decreases in both contrast avoidance and worry symptoms, whereas the active control treatment did not.

    “Whereas Skilljoy led to significant decreases in both contrast avoidance and worry symptoms, the active control treatment did not.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [114] LaFreniere LS, 2022, Manuscript Under Review source

      The Results (Penn State Worry Questionnaire; page unavailable) report that SkillJoy significantly reduced worry from pretrial to posttrial while the active self-monitoring control did not. The paper discusses contrast avoidance as a rationale for the intervention, but the retrieved passages do not report a measured decrease in contrast avoidance. It also reports a significant worry decrease in the control group by follow-up, so the claim holds for worry only at posttrial. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisecitation

    In a meta-analysis of randomized controlled trials, psychotherapy showed a medium to large effect (g=0.76) whereas medication showed a small effect (g=0.38) on generalized anxiety disorder outcomes.

    “For example, a meta-analysis of RCTs found that psychotherapy showed a medium to large effect size (g = 0.76) whereas medication showed a small effect size on GAD outcomes (g = 0.38) [10].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisecitation

    A worry outcome journal led to greater pre-post reduction in worry (d=-0.59) than a thought log, and was marginally superior on pre- to 20-day follow-up (d=-0.52), with gains maintained.

    “The worry outcome condition led to greater pre-post reduction in worry (d = −0.59) and was marginally superior to the thought log on pre- to 20-day follow-up (d = − 0.52), with gains maintained over the follow-up period.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • Classified as probably not a substantial claim.

    Premisecitation

    The Contrast Avoidance model posits that people with generalized anxiety disorder fear sharp increases in their negative emotions.

    “Specifically, CAM posits that people with GAD fear sharp increases in their negative emotions.”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [108] source
    • cites [109] source
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisecitation

    Individual cognitive behavioral therapy was not significantly different from SSRIs, but combined treatment was superior to either treatment alone at post-test.

    “Individual CBT was not significantly different from SSRIs, but the combined treatment was superior to either treatment alone at post-test.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [118] source

      The “CBT modalities versus SSRIs” section reports no significant difference between individual CBT and SSRIs. The “CBT modalities versus combination of CBT and SSRIs” section finds a significant benefit for combined treatment over individual CBT, but the passages do not establish that it was superior to SSRIs alone at post-test. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationcitation

    Positive mood enhancement strategies such as behavioral activation, lovingkindness, savoring, mindfulness of pleasure, gratitude, and moral elevation may be of interest, in line with preliminary but promising findings of interventions focused on extending and enhancing positive states.

    “Positive mood enhancement strategies such as behavioral activation, lovingkindness, savoring, mindfulness of pleasure, gratitude, and moral elevation may be of interest, in line with preliminary but promising findings of interventions focused on extending and enhancing positive states [114,126].”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [114] LaFreniere LS, 2022, Manuscript Under Review source
    • cites [126] source
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisecitation

    A few pilot studies have reported treatment efficacy in African American, Latino or mixed racially or ethnically diverse groups with generalized anxiety disorder, though these require replication with more rigorous methodologies.

    “A few pilot studies have reported treatment efficacy in African American, Latino or mixed racially or ethnically diverse groups with GAD [e.g., 120,121,122], though these require replication with more rigorous methodologies.”
    Quote in the paperNot a substantial claim3 of 3 sources checked
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Interpretationcitation

    Extant measures take for granted that worry is a future-oriented, verbal-linguistic thought process, despite worries overlapping with perseverative thinking about past failures, obsessions, or trauma-related intrusive thoughts.

    “In addition, extant measures take for granted that worry is a future-oriented, verbal-linguistic thought process, despite the fact that worries overlap markedly or can be confused by clients with perseverative thinking about past failures, obsessions, or trauma-related intrusive thoughts [123].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [123] source

      The Measurement Concerns section (page unavailable) says that existing measures can blur worry and obsessions, and that defining worry by assumed distinguishing features such as temporal orientation can bias responses. The Distinct Features section describes worry as future-focused and rumination as focused on past negative events. Our copy does not establish that measures assume worry is verbal-linguistic, or discuss confusion with trauma-related intrusive thoughts or past failures specifically. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisecitation

    Overall, cognitive behavioral therapy in various modalities was superior to waitlist, showed mixed beneficial effects compared to attention controls, and did not outperform treatment as usual.

    “Overall, CBT in various modalities was superior to waitlist, showed mixed beneficial effects compared to attention controls, and did not outperform TAU.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [118] source

      The Abstract and Discussion report that several CBT modalities outperformed waitlist controls and that results against attention controls varied by modality. The claim overgeneralizes the TAU comparison: the Individual-based CBT versus TAU section finds no significant benefit, but the Group-based CBT versus TAU section reports a significant benefit; the Abstract also reports family-based CBT as superior to TAU. Page numbers are not provided in our copy. (LLM, conf=0.90)

      Experimental — accuracy not yet measured
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Findingcitation

    Cognitive therapy is more effective than no treatment or placebo for generalized anxiety disorder, with a large between-group effect size of d = 1.15, and gains are maintained at 6 and 12 months.

    “CT was more effective than no-treatment or placebo with a large between-group effect size (d =1.15), and maintained gains at 6- and 12-month follow-up [21].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [21] source

  • May combine two claims.

    Findingcitation

    Self-control desensitization does not differ significantly from combined CBT or cognitive therapy alone for generalized anxiety disorder, and anxiety symptom improvements are maintained at two-year follow-up.

    “SCD’s efficacy was not significantly different from combined CBT and CT alone for GAD, and improvements in anxiety symptoms were maintained at 2-year follow-up [20].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] source

  • May combine two claims.

    Findingcitation

    Remission rates for generalized anxiety disorder after CBT are 51.4% at posttreatment and 65% at follow-up.

    “Rates of remission (complete recovery) for GAD were 51.4% at posttreatment and 65% at follow-up [11].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] source

  • May combine two claims.

    Findingcitation

    Cognitive therapy effects appear stronger than waiting-list control, with large posttreatment effect sizes of d = 1.8 (95% CI 1.26 to 2.37).

    “effects of CT appeared stronger than waiting-list (large posttreatment effect sizes, d = 1.8, 95% CI [1.26, 2.37])”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] source

  • May combine two claims.

    Findingcitation

    Individual intolerance of uncertainty therapy reduces anxiety, depression, worry, generalized anxiety disorder severity (ds 0.87 to 3.19), and intolerance of uncertainty from pre- to post-therapy, with gains maintained over 6- and 12-month follow-ups.

    “When administered in individual sessions, IUT led to reductions in anxiety, depression, worry, and GAD severity (ds ranging 0.87 to 3.19) and intolerance of uncertainty from pre- to post-therapy (with gains maintained over 6- and 12- month follow ups) [71].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [71] source

  • May combine two claims.

    Findingcitation

    Intolerance of uncertainty therapy was superior to SSRIs at posttreatment on worry (ηp2 = 0.36), intolerance of uncertainty (ηp2 = 0.65), and negative problem orientation (ηp2 = 0.30).

    “IUT was superior to SSRIs at posttreatment on levels of worry (ηp2=0.36), intolerance of uncertainty (ηp2=0.65), and negative problem orientation (ηp2=0.30).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [75] source

  • May combine two claims.

    Findingcitation

    Group intolerance of uncertainty therapy reduces anxiety, depression, worry, generalized anxiety disorder severity, and intolerance of uncertainty from pre- to post-therapy (ds 0.59 to 1.76), with gains maintained over a two-year follow-up.

    “group IUT led to reductions in anxiety, depression, worry, GAD severity, and intolerance of uncertainty from pre-to post-therapy (ds ranged = 0.59 to 1.76), with gains maintained over a 2-year follow-up [72].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [72] source

  • May combine two claims.

    Findingcitation

    At posttreatment, both metacognitive therapy and intolerance of uncertainty therapy are superior to delayed treatment, with metacognitive therapy superior to intolerance of uncertainty therapy on worry (d = 0.96) and general psychopathology (d = 0.55).

    “At posttreatment both MCT and IUT were superior to delayed treatment, with MCT superior to IUT on worry (d = 0.96) and general psychopathology (d = 0.55).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [76] source

  • May combine two claims.

    Findingcitation

    Metacognitive therapy was superior to applied relaxation in reducing worry, trait anxiety, depression, positive meta-cognitions, and negative meta-cognitions (ds 0.92 to 3.41 for metacognitive therapy; 0.27 to 1.63 for applied relaxation), with gains maintained over 6- and 12-month follow-ups.

    “MCT was superior to AR in reducing worry, trait anxiety, depression, positive meta-cognitions, and negative meta-cognitions (ds ranged 0.92 to 3.41 for MCT; 0.27 to 1.63 for AR), with gains maintained over 6- and 12- month follow-ups [78].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [78] source

  • May combine two claims.

    Interpretationcitation

    CBT and applied relaxation may have comparable effects in treating generalized anxiety disorder, whereas progressive muscle relaxation alone is inferior.

    “the current body of research suggests that CBT and AR may have comparable effects in the treatment of GAD, but PMR alone was inferior.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    Cognitive therapy appears well established for generalized anxiety disorder, but fewer than half of patients recover by the end of treatment and long-term follow-up data are sparse.

    “whereas CT appears to be well established for GAD, less than 50% recovered at the end of the treatment and long-term follow-up data are sparse [22].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] source

  • May combine two claims.

    Interpretationcitation

    Metacognitive therapy shows strong promise in treating generalized anxiety disorder and in single studies has outperformed intolerance of uncertainty therapy, CBT, and applied relaxation.

    “MCT shows strong promise in treating GAD and in single studies has outperformed IUT, CBT, and AR.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Mindfulness-based interventions appear efficacious for treating generalized anxiety disorder, but more research is needed to clarify their mechanisms of action and their comparison with CBT.

    “MBIs appear to be efficacious for treating GAD, but more research is needed to clarify the mechanisms of action and comparison against CBT.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Studies consistently support the efficacy of intolerance of uncertainty therapy for individuals across the lifespan with generalized anxiety disorder, with results maintained at follow-up.

    “studies consistently support the efficacy of IUT for individuals across the lifespan with GAD, with results maintained at follow-up points.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Findings overall reflect promise for emotion regulation therapy, but it requires comparison to a more active comparison group and further examination in diverse samples.

    “findings overall reflect promise for ERT but require comparison to a more active comparison group and further examination in diverse samples.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    A systematic review of 27 trials of psychotherapy and pharmacotherapy for older adults with generalized anxiety disorder (age ≥55; n=2,373) found both treatments demonstrated efficacy for generalized anxiety disorder, with pooled effects for psychotherapy (OR=0.33, 95% CI 0.17-0.66) and pharmacotherapy (OR=0.32, 95% CI 0.18-0.54).

    “A systematic review was conducted on 27 trials of psychotherapy (e.g., CBT, Acceptance and Commitment Therapy) and pharmacotherapy (e.g., antidepressants, sedatives) for older adults with GAD (age ≥ 55; n = 2,373) [117]. Both treatments demonstrated efficacy for GAD, based on pooled effects for psychotherapy (OR = 0.33, 95% CI [0.17, 0.66]) and pharmacotherapy (OR = 0.32, 95% CI [0.18, 0.54]).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [117] source
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisecitation

    A recent study of internet-delivered cognitive behavioral therapy using 12 PowerPoint modules emailed to participants led to a reduction in anxiety relative to no therapy, with gains maintained at 6-month and 1-year follow-ups.

    “One of the most recent studies of ICBT examined 12 PowerPoint modules emailed to participants [103]. ICBT led to a reduction in anxiety relative to no therapy (no effect sizes provided), with gains maintained at 6-month and 1-year follow-ups.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [103] source
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisecitation

    In a systematic review of 9 randomized controlled trials of internet-delivered cognitive behavioral therapy for generalized anxiety disorder, all studies demonstrated large treatment effects, maintained up to 3 years after treatment.

    “In the other non-meta-analytic systematic review [101] of 9 RCTS of ICBT for GAD, all studies demonstrated large treatment effects, with results maintained up to 3 years after treatment.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [101] source
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Interpretationreasoning

    Worrying keeps individuals with generalized anxiety disorder in a state of vigilance and anxiety, so if something bad happens, they will not experience a sharp increase in negative emotion because they are already in a negative state.

    “Therefore, worrying keeps individuals with GAD in a state of vigilance and anxiety, and if something bad happens, they will not experience a sharp increase in their negative emotion, because they are already in a negative emotional state.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisecitation

    Lasting symptom remission is likely after cognitive behavioral therapy termination, whereas medication termination may lead to relapse.

    “In addition, research suggests that lasting symptom remission is likely after CBT termination, whereas medication termination may lead to relapse [98].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [98] source
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    The core tenets of the Contrast Avoidance Model have found support in experimental lab studies and in studies of daily life.

    “We look forward to studies of therapies informed by the Contrast Avoidance Model, given that the core tenets of the model have found support in experimental lab studies and in studies of daily life.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Interpretationnone given

    Technological interventions have shown some promise, but few have been compared to active comparison conditions.

    “Regarding efforts at dissemination, although technological interventions have shown some promise, few have been compared to active comparison conditions.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Extant trials have not been sufficiently powered to detect small differences between active treatments or between packages and standalone interventions.

    “One possible explanation is that extant trials have not been sufficiently powered to detect small differences between active treatments or between packages and standalone interventions, suggesting that future studies aiming to demonstrate superiority of particular interventions will require much larger samples.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisenone given

    Component analyses have shown that applied relaxation was superior to progressive muscle relaxation alone, but applied relaxation, cognitive therapy, and self-control desensitization were not significantly different in outcome to cognitive behavioral therapy.

    “Furthermore, component analyses have shown that AR was superior to PMR alone, but AR, cognitive therapy, and SCD were not significantly different in outcome to CBT.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Interpretationnone given

    Emotion regulation therapy, mindfulness interventions, intolerance of uncertainty therapy, technological interventions, and the unified protocol have demonstrated greater efficacy compared to nonactive controls.

    “In terms of efforts to improve upon CBT, emotion regulation therapy, mindfulness interventions, intolerance of uncertainty therapy, technological interventions, and the unified protocol have demonstrated greater efficacy compared to nonactive controls.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Interpretationnone given

    Most studies have found nonsignificant differences between enhanced treatments compared to other active treatments and/or have yet to be tested in comparison to active treatments.

    “Nonetheless, most studies have found nonsignificant differences between enhanced treatments compared to other active treatments and/or have yet to be tested in comparison to active treatments.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisecitation

    Experiencing racism can increase rates of generalized anxiety disorder in people of color, and LGBTQ+ populations receive generalized anxiety disorder diagnoses at higher rates than the general public, possibly due in part to experiences with harassment and rejection.

    “This is troubling considering that experiencing racism can increase rates of GAD in people of color, and LGBTQ+ populations receive GAD diagnoses at higher rates than the general public, possibly due in part to experiences with harassment and rejection [see 119 for a review].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [119] source
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Interpretationnone given

    Overall cognitive behavioral therapy has demonstrated greater efficacy than no treatment, pill placebo, and psychological placebo with large effect sizes and gains maintained at follow-up.

    “Overall CBT has demonstrated greater efficacy than no treatment, pill placebo, and psychological placebo with large effect sizes and gains maintained at follow-up.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisecitation

    Racial and ethnic minorities have demonstrated significantly higher dropout rates and lack of access to high quality and culturally competent care compared to the general population, and also report experiencing more harm in treatment.

    “However, racial and ethnic minorities have demonstrated significantly higher dropout rates and lack of access to high quality and culturally competent care compared to the general population, and also report experiencing more harm in treatment [see 119].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [119] source
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisenone given

    Intolerance of uncertainty therapy was superior to SSRIs, whereas metacognitive therapy was superior to intolerance of uncertainty therapy and cognitive behavioral therapy.

    “Furthermore, intolerance of uncertainty therapy was superior to SSRIs, whereas metacognitive therapy was superior to intolerance of uncertainty therapy and CBT.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    One limitation of the narrative review is that it included meta-analytic findings that often group together heterogeneous studies of mixed methodological rigor, which may obscure important effects of particular interventions for particular populations.

    “One of the limitations of our narrative review is that we included meta-analytic findings that often group together heterogenous studies of mixed methodological rigor, which in some cases may obscure important effects of particular interventions for particular populations.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    Most psychotherapy research assumes that primary and secondary diagnoses represent distinct conditions rather than different expressions of shared underlying vulnerabilities.

    “Namely, most psychotherapy research suffers from the assumption that primary and secondary diagnoses represent distinct conditions rather than different expressions of shared underlying vulnerabilities.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

  • May combine two claims.

    Premisecitation

    Multicomponent cognitive behavioral therapy packages often do not outperform standalone interventions, such as cognitive behavioral therapy faring no better than applied relaxation.

    “Moreover, packages often do not typically outperform standalone interventions—such as CBT faring no better than applied relaxation [19].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [19] source
    • Rests on an assumption: The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.
    • Rests on an assumption: The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.
    • Rests on an assumption: The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.
67 of 67

  • The paper relies on this without support.

    No treatment for generalized anxiety disorder works for every patient.

    “but no treatment works for everyone.”

  • The paper relies on this without support.

    The meta-analyses and randomized controlled trials cited in this review provide valid estimates of treatment efficacy for generalized anxiety disorder.

    “One of the limitations of our narrative review is that we included meta-analytic findings that often group together heterogenous studies of mixed methodological rigor, which in some cases may obscure important effects of particular interventions for particular populations.”

  • The paper relies on this without support.

    The diagnostic criteria and outcome measures used across the cited studies are sufficiently comparable to allow synthesis.

    “One of the limitations of our narrative review is that we included meta-analytic findings that often group together heterogenous studies of mixed methodological rigor, which in some cases may obscure important effects of particular interventions for particular populations.”

  • The paper relies on this without support.

    The treatments classified as cognitive behavioral therapy or its enhancements are sufficiently similar across studies to be compared.

    “One of the limitations of our narrative review is that we included meta-analytic findings that often group together heterogenous studies of mixed methodological rigor, which in some cases may obscure important effects of particular interventions for particular populations.”
4 of 4

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • The same citation is assigned to different treatment comparisons

    Minor

    Reference [75] is used for a comparison of metacognitive therapy with IUT, but earlier it identifies a comparison of IUT with SSRIs. The paper separately assigns the metacognitive-therapy comparison to [76].

  • Effect estimate falls outside its reported confidence interval

    Minor

    The reported effect of 0.27 is above the confidence interval's upper bound of 0.02. The interval's midpoint is −0.25, suggesting that the effect estimate or an interval bound is wrong.

    Reported 0.27 · recomputed -0.25

  • Conclusion misidentifies the comparison treatment

    Minor

    The conclusion describes a benefit over CBT alone for clients with dismissive childhood attachment. The earlier account says the comparison was CBT plus supportive listening, not CBT alone.

3 of 3

Cites

Flagged first, then by citations

6 of the 127 references couldn’t be matched to a known paper.

Research works printed but not linked: 10

  1. Newman MG, 2021, Bergin and Garfield Handbook of Psychotherapy and Behavior Change, 469
  2. Craske MG, 1992, Mastery of your anxiety and worry
  3. Hedman-Lagerlöf M, 2018, Psychol Med, 1
  4. Arkowitz H, 2008, Motivational interviewing in the treatment of psychological problems. Applications of motivational interviewing, 324
  5. Rubak S, 2005, Br J Gen Pract, 55, 305
  6. Hara KM, 2021, Psychother Res, 1
  7. LaFreniere LS, 2022, Manuscript Under Review
  8. LaFreniere LS, 2022, Manuscript under review
  9. Llera SJ, 42nd annual meeting of the anxiety and depression association of America
  10. Llera SJ, 55th Annual Meeting of the Association for Behavioral and Cognitive Therapies

Cited by

Sorted by citations

Related

Authors
Newman, M. G., Basterfield, C., Erickson, T. M., Caulley, E., Przeworski, A., & Llera, S. J.
Affiliations
  • Pennsylvania State University (US)
  • Seattle Pacific University (US)
  • Case Western Reserve University (US)
  • Towson University (US)
Corresponding author
Newman, Michelle G.
ORCID
Venue
Expert Review of Neurotherapeutics
Publisher
Informa UK Limited
Published
2022-09-02
Volume
22
Issue
9
Pages
751-770
ISSN
  • 1473-7175 (ISSN-L)
  • 1744-8360
DOI
10.1080/14737175.2022.2125800
PMC
PMC9754763
OpenAlex
W4295903892
Cited by
27
References
127
Citations by year
2026: 8 · 2025: 14 · 2024: 1 · 2023: 3 · 2022: 1
FWCI
3.51
Type
journal article
Language
en
Open access
Locations
  • Expert Review of Neurotherapeutics (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (submittedVersion)
  • ScholarSphere (Penn State Libraries) (submittedVersion, cc-by)
Funders
paper was funded by the National Institute of Mental Health (R01 MH115128)
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
  • Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
Keywords
generalized anxiety disorder, cognitive behavioral therapy, psychotherapy, treatment enhancement, interpersonal psychotherapy, emotion regulation therapy, Unified Protocol, metacognitive therapy
MeSH terms
Anxiety Disorders, Behavior Therapy, Cognition, Humans, Psychotropic Drugs, Cognitive Behavioral Therapy, Treatment Outcome

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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