Approaching cognitive behavior therapy for generalized anxiety disorder from a cognitive process perspective
Open accessAbstract
Generalised anxiety disorder (GAD), with uncontrollable worry at its core, is a common psychological disorder with considerable individual and societal costs. Cognitive behaviour therapy (CBT) is recommended as the first-line treatment for GAD; however, further investigation into its effectiveness in routine clinical care is indicated and improvement is required in treatment outcomes for worry. Improvements to CBT need to be guided by experimental research that identifies key mechanisms maintaining core aspects of the disorder. This paper summarises how theory-driven experimental research guided selection and refinements of CBT techniques originally developed by Borkovec and Costello (1993), to target key cognitive processes that maintain worry in GAD. Hirsch and Mathews’ (2012) model specifies three key research-supported processes that maintain uncontrollable worry in GAD: implicit cognitive biases such as negative interpretation bias and attention bias, generalised verbal thinking style, and impaired ability to re-direct attentional control away from worry. Specific CBT techniques outlined in this paper aim to target these key processes. Clinical data from clients treated using our refined CBT protocol for GAD in a routine clinical care service with a special interest in anxiety disorders were collected as part of service procedures. Large pre-to-posttreatment effect sizes were obtained for anxiety (GAD-7), depression (PHQ-9), and worry (PSWQ) (d=.90-2.54), and a moderate effect size was obtained for quality of life (WASA; d=.74). Recovery was indicated for 74% of cases for anxiety, 78% for depression, and 53% for worry. These findings exceeded most previous effectiveness studies in routine care and were in-line with GAD efficacy trials. This paper also outlines the application of specific clinical techniques selected, adapted or developed to target key cognitive mechanisms which maintain worry in GAD.
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It is not clear which CBT protocol is most effective and most suitable in primary care settings.
“It is not clear which CBT protocol is most effective and most suitable in primary care settings. There are several systematic reviews of the different protocols [19, 23–26], but there are few studies per protocol, and many studies have small sample sizes and/or used waitlist controls.”
From Intolerance-of-uncertainty therapy versus metacognitive therapy for generalized anxiety disorder in primary health care: A randomized controlled pilot trial (2023) · cites this paper as [26]
The Introduction (Psychological Therapies for GAD; page unavailable) says that several CBT protocols are recommended, and the Discussion (page unavailable) says this audit cannot isolate the effect of its protocol refinements. These passages are consistent with uncertainty about which protocol is most effective, but the paper does not assess which is most suitable for primary care settings. (LLM, conf=0.78)
Experimental — accuracy not yet measuredIndividual CBT leads to moderate to large improvements in chronic worry severity, GAD symptom severity, and depression symptom severity in frontline settings.
“there is promising support that individual CBT leads to moderate to large improvements in chronic worry severity, GAD symptom severity, and depression symptom severity (e.g. Hirsch et al ., 2019; Kehle, 2008)”
From Effectiveness and predictors of group cognitive behaviour therapy outcome for generalised anxiety disorder in an out-patient hospital setting (2024) · cites this paper as Hirsch et al., 2019
Previous evidence underlined the effectiveness of cognitive interventions focused both on symptoms and cognitive dysfunctional processes present in GAD, like worries.
“Previous evidence underlined the effectiveness of cognitive interventions focused both on symptoms and cognitive dysfunctional processes present in GAD, like worries (Covin et al., 2008; Hirsch et al., 2019; Miller et al., 2021).”
From Standard CBT versus integrative and multimodal CBT assisted by virtual-reality for generalized anxiety disorder (2022) · cites this paper as Hirsch et al., 2019
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What if we have too many models of worry and GAD?
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Popa, C. O., Sava, F. A., Muresan, S., Schenk, A., Cojocaru, C. M., Muntean, L. M., & Olah, P. (2022) · Frontiers in Psychology · doi:10.3389/fpsyg.2022.1008981 · Cited by 14 · see citing works
“Besides these specific symptoms, different cognitive and attentional biases, such as the overestimation of a hypothetic threat or underestimation of one’s capacity to manage stressful situations were described as GAD characteristics (Hirsch et al., 2019).”
BackgroundParticulate Matter Exposure and Default Mode Network Equilibrium During Early Adolescence
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Revised Beckian cognitive therapy for generalised anxiety disorder
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“…studies that have investigated the effectiveness of CBT for GAD in frontline settings, there is promising support that individual CBT leads to moderate to large improvements in chronic worry severity, GAD symptom severity, and depression symptom severity (e.g. Hirsch et al ., 2019; Kehle, 2008).”
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“There is also a tendency in GAD toward negatively biased interpretations about ambiguous issues [cf. cognitive model; 31, 32].”
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- Authors
- Hirsch, C. R., Beale, S., Grey, N., & Liness, S.
- Affiliations
- King's College London (GB)
- Sussex Partnership NHS Foundation Trust (GB)
- Corresponding author
- Hirsch, Colette R.
- Venue
- Frontiers in Psychiatry
- Publisher
- Frontiers Media SA
- Published
- 2019-11-04
- Volume
- 10
- Pages
- 796-796
- ISSN
- 1664-0640 (ISSN-L)
- PMC
- PMC6852150
- OpenAlex
- W2981972182
- Cited by
- 43
- References
- 97
- Citations by year
- 2026: 10 · 2025: 8 · 2024: 7 · 2023: 6 · 2022: 7 · 2021: 1 · 2020: 4
- FWCI
- 3.54
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Frontiers in Psychiatry (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- South London and Maudsley NHS Foundation Trust
- National Institute for Health and Care Research
- King's College London
- 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, cognitive behavioral therapy, worry, cognitive processes, negative interpretation bias, attentional bias, attentional control, treatment effectiveness, routine clinical practice, depression, quality of life
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