Worry exposure versus applied relaxation in the treatment of generalized anxiety disorder
Open accessAbstract
Background: Worry exposure (WE) is a core element of cognitive-behavioral treatment for generalized anxiety disorder (GAD). Its efficacy as a stand-alone treatment method (without further cognitive-behavioral therapy interventions) has never been tested.We aimed to examine whether WE alone is as efficacious as the empirically supported stand-alone treatment for GAD, applied relaxation (AR). Methods: In a randomized controlled study, 73 outpatients meeting DSM-IV criteria for GAD as primary diagnosis were allocated to either WE or AR or a waiting list control group; in a 2nd randomization procedure the waiting list subjects were reallocated to WE or AR. The treatment was manualized (15 sessions with WE or AR), included 6-month and 1-year follow-ups, as well as last observation carried forward and completer analyses, and was controlled for allegiance effects.The Hamilton Anxiety Rating Scale and the State-Trait Anxiety Scale were used as primary outcome measures. Self-report scales of anxiety, worrying and depression including negative metacognition about worrying and thought suppression served as secondary outcome measures. Results: The dropout rate was moderate. The pre-/posttreatment effects were high for the Hamilton Anxiety Rating Scale (standardized mean difference >1) and for the State-Trait Anxiety Inventory (standardized mean difference >0.87). The proportion of patients reaching high end state functioning was 48% (WE) and 56% (AR). WE and AR did not differ with regard to dropout rate or treatment effects. The treatment effects were stable at 6 month and 1 year follow-up. Conclusion: This is the first study to show that a stand-alone exposure in sensu technique – WE – is efficacious in the treatment of GAD. Both AR and WE seem to represent effective principles of change in GAD.
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Earlier attempts to use exposure in GAD relied on imagery to bring up worrisome fears.
“Prior efforts to implement exposure within GAD used techniques that induced worrisome fears via imagery (Hoyer et al., 2009; Zinbarg, Lee, & Yoon, 2007).”
From A novel theory of experiential avoidance in generalized anxiety disorder: A review and synthesis of research supporting a contrast avoidance model of worry (2011) · cites this paper as Hoyer et al., 2009
Applied relaxation was roughly as efficacious as worry exposure in treating generalized anxiety disorder.
“For example, randomized controlled trials demonstrated that AR was more efficacious than a nondirective, reflective listening therapy (Borkovec & Costello, 1993) and roughly as efficacious as cognitive therapy (Arntz, 2003; Öst & Breitholtz, 2000), cognitive behavioral therapy (Borkovec & Costello, 1993; Dugas et al., 2010), and worry exposure (Hoyer et al., 2009) in treating GAD.”
From A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder (2013) · cites this paper as Hoyer et al., 2009
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].”
From Psychotherapeutic treatments for generalized anxiety disorder: cognitive and behavioral therapies, enhancement strategies, and emerging efforts (2022) · cites this paper as [25]
Experimental — accuracy not yet measuredA treatment concept that uses worry exposure alone to target pathological worries is equally effective, as shown in a recent controlled study.
“Dass eine Behandlungskonzeption, die mittels Sorgenexposition allein auf die pathologischen Sorgen abzielt, ebenso effektiv ist, konnten wir kürzlich in einer kontrollierten Studie zeigen [Hoyer et al., 2009].”
From Wann sind Sorgen pathologisch? (2009) · cites this paper as Hoyer et al., 2009
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A Self-Paced Relaxation Response Detection System Based on Galvanic Skin Response Analysis
Martínez, R., Salazar-Ramirez, A., Arruti, A., Irigoyen, E., Martin, J. I., & Muguerza, J. (2019) · IEEE Access · doi:10.1109/access.2019.2908445 · Cited by 28 · see citing works
“In fact, if mental or physical relaxation is achieved, particularly effective results can be obtained when seeking to improve some of the most common problems of clinical psychology, such as stress, anxiety disorders or depression [10]–[12].”
BackgroundFlückiger, C., Zinbarg, R. E., Znoj, H., & Ackert, M. (2014) · Psychotherapy · doi:10.1037/a0034119 · Cited by 26 · see citing works
“Patients with GAD often avoid experiencing their own weaknesses in a concrete, active, vivid, and emotional manner (Stöber & Borkovec, 2002), and talking about one’s own weaknesses in a concrete and emotional manner could be an observable indicator of breaking through experiential avoidance in patients with GAD (Hoyer…”
BackgroundOvanessian, M. M., Koerner, N., Antony, M. M., & Dugas, M. J. (2019) · Journal of Experimental Psychopathology · doi:10.1177/2043808719841529 · Cited by 27 · see citing works
“The efficacy of imaginal exposure for GAD has been examined independently of other CBT techniques in only a few studies (Hoyer et al., 2009; Provencher, Dugas, & Ladouceur, 2004).”
MethodCognitive-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-citationPsychotherapy for Generalized Anxiety Disorder
Hoyer, J., van der Heiden, C., & Portman, M. (2011) · Psychiatric Annals · doi:10.3928/00485713-20110203-07 · Cited by 9 · see citing works
Self-citationJansson‐Fröjmark, M., Lind, M., & Sunnhed, R. (2011) · British Journal of Clinical Psychology · doi:10.1111/j.2044-8260.2011.02018.x · Cited by 22 · see citing works
“One intervention type that might be worth exploring within an insomnia context are methods that replace cognitive avoidance with an approach towards thoughts and feelings, thereby providing habituation, for example, worry exposure, worry periods, and Pennebaker-style writing intervention (Harvey & Farrell, 2003; Hauri…”
MethodHearn, C. S., Donovan, C. L., Spence, S. H., & March, S. (2018) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2017.11.005 · Cited by 21 · see citing works
Cognitive-behavior therapy resolves implicit fear associations in generalized anxiety disorder.
Reinecke, A., Rinck, M., Becker, E., & Hoyer, J. (2013) · Behaviour Research and Therapy · doi:10.1016/j.brat.2012.10.004 · Cited by 25 · see citing works
“Patients were recruited from a larger-scale clinical trial designed to compare the impact of two different treatment approaches on GAD symptom severity (Hoyer et al., 2009), resulting in some of the patients receiving worry exposure CBT (N1⁄4 13; Becker &Margraf, 2002), and others receiving applied relaxation CBT (N1⁄…”
MethodResultSelf-citationPsychological interventions in the treatment of generalized anxiety disorder: a structured review
Bolognesi, F., Baldwin, D. S., & Ruini, C. (2014) · ePrints Soton (University of Southampton) · Cited by 16 · see citing works
The feasibility of verbal and virtual reality exposure for youth with academic performance worry
Whiteside, S. P. H., Brennan, E., Biggs, B. K., Vickers, K. S., Hathaway, J. C., Seifert, S. J., Kramer, K. M., & Hofschulte, D. R. (2020) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2020.102298 · Cited by 16 · see citing works
Hendriks, G., Janssen, N., Robertson, L., van Balkom, A. J. L. M., van Zelst, W. H., Wolfe, S., Voshaar, R. C. O., & Uphoff, E. (2024) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd007674.pub3 · Cited by 20 · see citing works
Cognitive-behavioural therapy reduces unwanted thought intrusions in generalized anxiety disorder
Reinecke, A., Hoyer, J., Rinck, M., & Becker, E. S. (2012) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2012.06.003 · Cited by 16 · see citing works
“from a larger-scale clinical trial that aimed at comparing the impact of two different treatment approaches on GAD symptom severity (Hoyer et al., 2009).”
BackgroundInfluentialSelf-citationThe importance of problem-focused treatments: A meta-analysis of anxiety treatments.
Yulish, N. E., Goldberg, S. B., Frost, N. D., Abbas, M., Oleen-Junk, N. A., Kring, M., Chin, M. Y., Raines, C. R., Soma, C. S., & Wampold, B. E. (2017) · Psychotherapy · doi:10.1037/pst0000144 · Cited by 16 · see citing works
Zhang, W., Du, Y., Yang, X., Wang, E., Fang, J., Liu, Z., Wu, S., Liu, Q., & Hu, Y. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.832167 · Cited by 15 · see citing works
Negative Thoughts and Metacognitions in Anxious Children Following CBT
Normann, N., Lønfeldt, N. N., Reinholdt‐Dunne, M. L., & Esbjørn, B. H. (2015) · Cognitive Therapy and Research · doi:10.1007/s10608-015-9740-2 · Cited by 15 · see citing works
“Other adult studies have also assessed metacognitive changes during cognitive and/or behavioral therapies and found significant decreases during the course of treatment (Hoyer et al. 2009; McEvoy et al. 2009; McEvoy and Perini 2009; van der Heiden et al. 2012; Wells et al. 2010; Westra et al. 2009).”
Prolonged Imaginal Exposure Based on Worry Scenarios
Hoyer, J., & Beesdo-Baum, K. (2012) · Springer eBooks · doi:10.1007/978-1-4614-3342-2_14 · Cited by 17 · see citing works
Self-citationLognoul, M., Nasello, J., & Triffaux, J. (2020) · L Encéphale · doi:10.1016/j.encep.2020.01.005 · Cited by 14 · see citing works
Berg, H. E., Akeman, E., McDermott, T. J., Cosgrove, K. T., Kirlić, N., Clausen, A. N., Cannon, M., Yeh, H., White, E. J., Thompson, W. K., et al. (2023) · Journal of Mood and Anxiety Disorders · doi:10.1016/j.xjmad.2023.100004 · Cited by 14 · see citing works
“The present study did not include a control group (e.g., waitlist), given that the effectiveness of EXP for GAD has already been demonstrated [18,19]; however, this limits our ability to identify treatment-specific effects.”
Health anxiety amplifies fearful responses to illness-related imagery
Benke, C., Wallenfels, L.-M., Bleichhardt, G. M., & Melzig, C. A. (2024) · Scientific Reports · doi:10.1038/s41598-024-54985-y · Cited by 13 · see citing works
Katzman, M. A., Bleau, P., Blier, P., Chokka, P. R., Kjernisted, K. D., & Ameringen, M. V. (2021) · doi:10.32920/14638581 · Cited by 13 · see citing works
Mahoney, A., Newby, J. M., Hobbs, M. J., Williams, A. D., & Andrews, G. (2017) · Internet Interventions · doi:10.1016/j.invent.2017.11.004 · Cited by 12 · see citing works
Synthesis and neurotropic activity of new 3-(arylmethyl)aminopyridine-2(1H)-one
Palamarchuk, I. V., Shulgau, Z., Kharitonova, M. A., & Kulakov, I. V. (2021) · Chemical Papers · doi:10.1007/s11696-021-01696-7 · Cited by 12 · see citing works
The Effectiveness of Relaxation Therapy in the Reduction of Anxiety Related Symptoms (A Case Study)
Ali, U., & Hasan, S. (2010) · International Journal of Psychological Studies · doi:10.5539/ijps.v2n2p202 · Cited by 18 · see citing works
“Somewhat recently Hoyer et al. (2009) investigated the efficacy of worry exposure and applied relaxation therapeutic techniques for the treatment of generalized anxiety disorder, while comparing with control group both were found to be effective.”
BackgroundMarcotte-Beaumier, G., Bouchard, S., Gosselin, P., Langlois, F., Belleville, G., Marchand, A., & Dugas, M. J. (2021) · JMIR Mental Health · doi:10.2196/24541 · Cited by 11 · see citing works
“However, 2 studies did not find such a result following face-to-face CBT [33] or internet-delivered CBT [34].”
BackgroundPsychotherapie der Angststörungen: State of the Art
Hoyer, J., & Lueken, U. (2021) · Der Nervenarzt · doi:10.1007/s00115-021-01069-1 · Cited by 11 · see citing works
“die mit ihr verbundene Erfahrung – kann bereits zur Veränderung kognitiver Annahmen über die Angst führen [12]: „Ich weiß, was ich erlebt habe.”
BackgroundSelf-citationRogiers, R., Baeken, C., den Abbeele, D. V., Watkins, E. R., Remue, J., Colman, R., Raedt, R. D., & Lemmens, G. M. D. (2021) · Cognitive Therapy and Research · doi:10.1007/s10608-021-10240-6 · Cited by 11 · see citing works
Health anxiety is associated with fearful imagery of contracting COVID-19: An experimental study
Benke, C., Schönborn, T., Habermann, N., & Pané‐Farré, C. A. (2021) · Journal of Affective Disorders · doi:10.1016/j.jad.2021.11.014 · Cited by 10 · see citing works
“Moreover, mental imagery of feared situations, cues or events has been successfully implemented in the treatment of PTSD and various anxiety disorders (Holmes et al., 2007; Wild et al., 2008; Hoyer et al., 2009; Neudeck and Wittchen, 2012).”
BackgroundPrakash, S., Khapre, P., Laha, S., & Saran, N. (2011) · Indian Journal of Occupational and Environmental Medicine · doi:10.4103/0019-5278.93201 · Cited by 10 · see citing works
„Positive Nebenwirkungen“ von Psychotherapie
Hoyer, J. (2016) · Zeitschrift für Klinische Psychologie und Psychotherapie · doi:10.1026/1616-3443/a000370 · Cited by 9 · see citing works
Self-citationBroicher, T., Gerlach, A. L., & Neudeck, P. (2017) · Zeitschrift für Klinische Psychologie und Psychotherapie · doi:10.1026/1616-3443/a000415 · Cited by 9 · see citing works
El uso de las técnicas de relajación en la práctica de una clínica de psicología
Blanco, C., Estupiñá, F., Labrador, F. J., Fernández-Arias, I., Bernardo-de-Quirós, M., & Gómez, L. (2014) · Anales de Psicología · doi:10.6018/analesps.30.2.158451 · Cited by 8 · see citing works
Birdsey, N. (2020) · The Cognitive Behaviour Therapist · doi:10.1017/s1754470x20000410 · Cited by 9 · see citing works
“alternating behaviours on different days to permit time for hobbies that Ray found therapeutic, scheduling a ‘worry slot’ (Hoyer et al., 2009) to help manage the ‘shoulds’ that perpetuated Ray’s anxiety and low mood; managing the ‘mind bully’ (Vivyan, 2014) and responding to the ‘poisoned/pesky parrot’ (Vivyan, 2010),…”
BackgroundSchumacher, S., Schopka, N. M., Heinrich, M., & Knaevelsrud, C. (2018) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465818000371 · Cited by 6 · see citing works
“…of pathological anxiety, such as panic disorder with or without agoraphobia (Mitte, 2005; Sanchez-Meca et al., 2010), generalized anxiety disorder (Hoyer et al., 2009), specific phobia (Wolitzky-Taylor et al., 2008), but also post-traumatic stress disorder (PTSD; McLean and Foa, 2013) or…”
BackgroundAn Adaptation of the Coping Cat Program
Michael, K. D., Payne, L. O., & Albright, A. (2012) · Clinical Case Studies · doi:10.1177/1534650112460912 · Cited by 8 · see citing works
“Scheduled worry exposure, or worry time, also allows the client to express the worry that he or she is compelled to feel but to only do so for a certain amount of time each day, which eventually allows the client to habituate to his or her worries (Hoyer et al., 2009).”
BackgroundThe Role of Anxiety Control Strategies in Imaginal Exposure
Koerner, N., & Fracalanza, K. (2012) · Springer eBooks · doi:10.1007/978-1-4614-3342-2_12 · Cited by 8 · see citing works
Department of Psychology, F. O. E. A. P., Ghaderi, F., Akrami, N., Department of Psychology, F. O. E. A. P., Namdari, K., Department of Psychology, F. O. E. A. P., Abedi, A., & Department of Psychology and Education of Children with Special Needs, F. O. E. A. P. (2022) · Iranian Journal of Psychiatry and Clinical Psychology · doi:10.32598/ijpcp.27.4.3067.3 · Cited by 7 · see citing works
Neudeck, P., & Lang, T. (2020) · Klinische Psychologie & Psychotherapie · doi:10.1007/978-3-662-61814-1_26 · Cited by 7 · see citing works
Wann sind Sorgen pathologisch?
Hoyer, J., & Heidrich, S. (2009) · Verhaltenstherapie · doi:10.1159/000201938 · Cited by 6 · see citing works
“Dass eine Behandlungskonzeption, die mittels Sorgenexposition allein auf die pathologischen Sorgen abzielt, ebenso effektiv ist, konnten wir kürzlich in einer kontrollierten Studie zeigen [Hoyer et al., 2009].”
BackgroundSelf-citationTowards a unified worry exposure protocol for generalised anxiety disorder: A pilot study
McIntosh, C., & Crino, R. (2013) · Behaviour Change · doi:10.1017/bec.2013.19 · Cited by 6 · see citing works
“Currently, applied relaxation is the lone efficacious stand-alone treatment for GAD, although one study has suggested worry exposure may meet criteria if validated by further research (Hoyer et al., 2009).”
BackgroundResultInfluentialHoyer, J., & Niermann, H. C. M. (2020) · Verhaltenstherapie · doi:10.1159/000511096 · Cited by 6 · see citing works
Self-citationAsselmann, E., Zenker, M., Rückert, F., Kische, H., Pieper, L., & Beesdo‐Baum, K. (2023) · PLoS ONE · doi:10.1371/journal.pone.0286750 · Cited by 6 · see citing works
Beesdo‐Baum, K., & Hilbert, K. (2015) · Springer eBooks · doi:10.1007/978-3-319-13060-6_1 · Cited by 7 · see citing works
A Feasibility Open Trial of a Brief Internet-Delivered Written Exposure Therapy for Worry
Roch-Gagné, M., & Talbot, F. (2019) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465818000693 · Cited by 5 · see citing works
“…the use of cognitive exposure to worry as a stand-alone treatment using imagery was also found in an RCT conducted among 73 outpatients diagnosed with GAD who were allocated either to worry exposure using imaginal exposure, applied relaxation or a waiting list control group (Hoyer et al., 2009).”
BackgroundMethodResultInfluentialCompetitive memory training (COMET) voor piekeren
Martens, S., Korrelboom, K., & Huijbrechts, I. P. A. M. (2009) · Directieve therapie · doi:10.1007/bf03087867 · Cited by 5 · see citing works
Self‐guided imagery rescripting for worry images: A preliminary experimental investigation
Stavropoulos, L., Briggs, N., & Grisham, J. R. (2024) · Journal of Clinical Psychology · doi:10.1002/jclp.23660 · Cited by 4 · see citing works
Becker, S., Witthöft, M., & Klan, T. (2018) · Verhaltenstherapie · doi:10.1159/000479890 · Cited by 3 · see citing works
“So wurden in randomisiert-kontrollierten Studien gute Ergebnisse bei Patienten mit Generalisierter Angststörung [z.B. Hoyer et al., 2009] und Spezifischer Phobie [z.B. Öst et al., 2001], aber auch bei Zwangsstörungen [z.B. Foa et al., 2005] erzielt.”
BackgroundRogiers, R., Parys, H. V., Baeken, C., den Abbeele, D. V., Remue, J., Raedt, R. D., & Lemmens, G. M. D. (2021) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12378 · Cited by 4 · see citing works
Virtual Reality for Anxiety and Stress-Related Disorders: A SWOT Analysis
Fernández‐Álvarez, J., Colombo, D., Botella, C., García‐Palacios, A., & Riva, G. (2019) · Lecture notes of the Institute for Computer Sciences, Social Informatics and Telecommunications Engineering · doi:10.1007/978-3-030-25872-6_4 · Cited by 5 · see citing works
“Although applying exposure to anxiety disorders is one of the few undisputable procedures in clinical psychology research [8], a number of studies have shown that both therapists [9–11] and patients [12, 13] are reluctant to undergoing in vivo exposure.”
BackgroundKrzikalla, C., Morina, N., Andor, T., Nohr, L., & Buhlmann, U. (2023) · PLoS ONE · doi:10.1371/journal.pone.0282902 · Cited by 3 · see citing works
“Only a few studies thus far have examined predictors of change in GAD directly in context with a therapeutic intervention [13, 44, 45] or in a naturalistic setting [44, 46–48].”
BackgroundGeneralized anxiety disorder: Assessment and treatment
Gerlach, A. L., & Stevens, S. (2014) · The Wiley Handbook of Anxiety Disorders · doi:10.1002/9781118775349.ch48 · Cited by 3 · see citing works
Zech, J. M., Patel, T. A., & Cougle, J. R. (2024) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2024.102909 · Cited by 3 · see citing works
The effectiveness of worry exposure in treating generalized anxiety disorder
Shahmoradi, G., Dadashi, M., Eskandari, Z., Iravani, M. R., Salimi, S., & Jannesari, H. (2013) · Management Science Letters · doi:10.5267/j.msl.2013.05.021 · Cited by 2 · see citing works
“According to Hoyer et al. (2009), WE is a core element of cognitive-behavioral treatment for GAD.”
BackgroundCarpenter, J. K., Conroy, K., & Hofmann, S. G. (2018) · Cambridge University Press eBooks · doi:10.1017/9781108140416.029 · Cited by 3 · see citing works
- Authors
- Hoyer, J., Beesdo, K., Gloster, A. T., Runge, J., Höfler, M., & Becker, E. S.
- Affiliations
- Technische Universität Dresden (DE)
- Radboud University Nijmegen (NL)
- Venue
- Psychotherapy and Psychosomatics
- Publisher
- S. Karger AG
- Published
- 2009
- Volume
- 78
- Issue
- 2
- Pages
- 106-115
- ISSN
- 0033-3190 (ISSN-L)
- 1423-0348
- OpenAlex
- W2126294400
- Cited by
- 147
- References
- 37
- Citations by year
- 2026: 4 · 2025: 2 · 2024: 10 · 2023: 6 · 2022: 5 · 2021: 15 · 2020: 15 · 2019: 7 · 2018: 6 · 2017: 12 · 2016: 4 · 2015: 6 · 2014: 12 · 2013: 9 · 2012: 10
- FWCI
- 14.36
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Psychotherapy and Psychosomatics (publishedVersion)
- PubMed (publishedVersion)
- edoc (University of Basel) (acceptedVersion)
- Radboud Repository (Radboud University) (submittedVersion)
- Qucosa (Saxon State and University Library Dresden) (submittedVersion, other-oa)
- edoc (University of Basel)
- Funders
- Pfizer
- Deutsche Forschungsgemeinschaft
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- generalized anxiety disorder, applied relaxation, cognitive behavioral therapy, thought suppression, dropout
- MeSH terms
- Adult, Anxiety Disorders, Depressive Disorder, Female, Humans, Life Change Events, Male, Surveys and Questionnaires, Relaxation Therapy, Thinking, Diagnostic and Statistical Manual of Mental Disorders
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