Exploring change in cognitive-behavioral therapy for generalized anxiety disorder—A two-arms ABAB crossed-therapist randomized clinical implementation trial.

Abstract

Objective: There is little evidence-based knowledge of how psychotherapists should handle both sudden gains and more gradual session-by-session changes, either in general or in individuals suffering from generalized anxiety disorder. Methods: Using an ABAB crossed-therapist randomized clinical implementation trial design (N = 80 patients and 20 therapists), we contrasted a Prolonged Focus on Change (PFC, N = 40) implementation with a State-Of-The-Art (SOTA, N = 40) implementation. Both implementations were based on a widely used cognitive behavioral therapy approach (Mastery of your Anxiety and Worry package) with the only difference that in the PFC implementation, the therapists were instructed to systematically explore eventual changes at the beginning of the therapy sessions. Results: Based on a 3-level hierarchical linear model, PFC implementation showed faster symptom reduction in worry over therapy (i.e., linear change) and a decelerated (quadratic) change until 12-month follow-up in comparison to the SOTA implementation. Conclusion: These findings provide clinically useful information about potential short-term and long-term effects of exploring occurring change in GAD populations. Randomized clinical implementation trial designs are a step forward allowing to experimentally investigate basic psychotherapeutic strategies in process-based psychotherapy.What is the public health significance of this article? This randomized clinical implementation trial provides empirical evidence for good clinical wisdom that exploring occurring change is helpful to facilitate further change during therapy. These results underscore the relevance of understanding patient's proactive engagement in change behaviors, competences, skills, and behavioral preferences in individuals that suffer from generalized anxiety disorder to positively impact worry outcomes.

The relative efficacy of bona fide cognitive behavioral therapy and applied relaxation for generalized anxiety disorder at follow-up: A longitudinal multilevel meta-analysis.

“…Well-established CBT refers to well-established CBT manuals for GAD (e.g., Borkovec et al, 2002; Zinbarg et al, 2006). The large majority of the augmented integrative CBT conditions are based on a well-established CBT for GAD manual and integrate additional therapeutic strategies such as motivational interviewing (Westra et al, 2016), interpersonal/emotional processing (Newman et al, 2011), strength-based strategies (Fava et al, 2005; Flückiger et al, 2016, 2021), ecological momentary interventions (Newman et al, 2014), and interventions from third wave CBT (Afshari & Hasani, 2020; Avdagic et al, 2014; Wetherell et al, 2011).…”

Worry and Positive Episodes in the Daily Lives of Individuals With Generalized Anxiety Disorder: An Ecological Momentary Assessment Study

“…Interrater agreement of the GAD diagnoses of structured interview was 95%; in the few cases of disagreement, the participants were excluded from the study. The primary aim of the trial was to investigate the enduring efficacy of cognitive-behavioral therapy for GAD ( Flückiger et al, 2021 Clinical trial registration: ClinicalTrials.gov #NCT03079336). Inclusion criteria were as: (1) meeting Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013 ) criteria for GAD; (2) being at least 18years old; and (3) giving informed consent.…”

“…The presence of comorbidities did not result in exclusion from the study if GAD was the primary diagnosis. For more details about the selection procedure, see Flückiger et al (2021) .…”

“…Interrater agreement of the GAD diagnoses of structured interview was 95%; in the few cases of disagreement, the participants were excluded from the study. The primary aim of the trial was to investigate the enduring efficacy of cognitivebehavioral therapy for GAD (Flückiger et al, 2021 (2) current medication for psychotic or bipolar disorder, or (3) current treatment from a professional psychotherapist. Prescribed medications for anxiety or depressive disorders did not lead to exclusion from the study if the dosage has remained constant for at least 1 month.…”

“…For more details about the selection procedure, see Flückiger et al (2021). Fifty-five individuals with GAD agreed to take part in the smartphone-based EMA.…”