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Generalized anxiety disorder (GAD) is associated with substantial personal and societal cost yet is the least successfully treated of the anxiety disorders. In this review, research on clinical features, boundary issues, and naturalistic course, as well as risk factors and maintaining mechanisms (cognitive, biological, neural, interpersonal, and developmental), are presented. A synthesis of these data points to a central role of emotional hyperreactivity, sensitivity to contrasting emotions, and dysfunctional attempts to cope with strong emotional shifts via worry. Consistent with the Contrast Avoidance model, evidence shows that worry evokes and sustains negative affect, thereby precluding sharp increases in negative emotion. We also review current treatment paradigms and suggest how the Contrast Avoidance model may help to target key fears and avoidance tendencies that serve to maintain pathology in GAD.

Background “Mindfulness-based” interventions show promise for stress-reduction in general medical conditions, and initial evidence suggests that they are well accepted in trauma-exposed individuals. Mindfulness-based Cognitive Therapy (MBCT) shows substantial efficacy for prevention of depression relapse, but it has been less studied in anxiety disorders. This study investigated the feasibility, acceptability, and clinical outcomes of an MBCT group intervention adapted for combat PTSD. Methods Consecutive patients seeking treatment for chronic PTSD (veterans of Vietnam, Korea, WWII, Desert Storm) at a VA outpatient clinic were enrolled in eight week MBCT groups, modified for PTSD (four groups, n=20) or brief treatment-as-usual (TAU) comparison group interventions (three groups, n=16). MBCT consisted of PTSD psychoeducation, mindfulness of body, breath, and emotions, mindful movement, exercises for managing intrusive thoughts and feelings, and daily home practice though audio recording. Pre- and post-therapy psychological assessments with clinician administered PTSD scale (CAPS) were performed with all patients, and self-report measures (PTSD diagnostic scale, PDS, and Posttraumatic cognitions inventory, PTCI) were administered in the MBCT group. Results Pre- to post-treatment effects analysis demonstrated significant improvement in PTSD symptoms. Intent to treat analyses showed significant improvement in CAPS (t(19)=4.8, p<.001) in the MBCT condition but not the TAU conditions, and a significant Condition*Time interaction (F[1,26]=16.4, p<.005). MBCT completers analysis (n =15, 75%) also showed good compliance with assigned homework exercises, and significant and clinically meaningful improvement in PTSD symptom severity on post-treatment assessment in CAPS and PDS (particularly in avoidance/numbing symptoms), and reduced PTSD-relevant cognitions in PTCI (in particular, self-blame). Conclusions These data suggest group mindfulness-based cognitive therapy as an acceptable brief intervention / adjunct therapy for combat PTSD, with potential for reducing avoidance symptom cluster and PTSD cognitions. Further studies are needed to examine efficacy in a randomized controlled design and to identify factors influencing acceptability and effectiveness.

Self-help materials, brief therapies, and treatments involving minimal therapist contact have all been proposed as effective and low-cost interventions for anxiety disorders. However, research also suggests that the therapeutic alliance is a central predictor of therapy outcome. Interestingly, amounts of therapist contact within and across "self-help" interventions vary greatly. It is therefore unclear how much therapist contact is necessary for a positive anxiety disorder treatment outcome. The present article reviews the literature on anxiety disorder treatments using self-help, self-administered, and decreased therapist-contact interventions. Treatment studies are grouped together by anxiety diagnosis as well as amount of therapist contact. It is concluded that self-administered treatments are most effective for motivated clients seeking treatment for simple phobias. Predominantly self-help therapies are efficacious for panic disorder and mixed anxiety samples. On the other hand, minimal-contact therapies have demonstrated efficacy for the greatest variety of anxiety diagnoses.

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