Efficacy of Applied Relaxation and Cognitive—Behavioral Therapy in the Treatment of Generalized Anxiety Disorder T. D. Borkovec Stress and Anxiety Disorders Institute Ellen Costello Stress and Anxiety Disorders Institute ABSTRACT Nondirective (ND), applied relaxation (AR), and cognitive behavioral (CBT) therapies for generalized anxiety disorder (GAD) were compared. The latter 2 conditions were generally equivalent in outcome but superior to ND at postassessment. The 3 conditions did not differ on several process measures, and ND created the greatest depth of emotional processing. Follow-up results indicated losses in gains in ND, maintained gains in the other 2 conditions, especially CBT, and highest endstate functioning for CBT. AR and CBT thus contain active ingredients in the treatment of GAD; support exists for further development of imagery exposure methods or cognitive therapy because of their likely role in promoting maintenance of change with this disorder. Expectancy for improvement was also associated with outcome, suggesting the need for further research on this construct for understanding the nature of GAD and its amelioration. This research was supported in part by National Institute of Mental Health Research Grant MH-39172 to T. D. Borkovec. We gratefully acknowledge the devoted contributions of Teresa Elliott, Milly Hopkins, Lenore Jacobs-Caffey, Jim Lyonfields, Rick Lytle, Tom Meyer, Sharon Posa, Liz Roemer, and Rich Shadick. Correspondence may be addressed to T. D. Borkovec, Department of Psychology, Pennsylvania State University, University Park, Pennsylvania, 16802. Received: July 13, 1992 Revised: September 23, 1992 Accepted: September 28, 1992 Controlled studies of cognitive—behavioral treatments (including relaxation, anxiety management, and cognitive therapy) for generalized anxiety disorder (GAD) have found these techniques to produce greater improvement than no treatment and to yield maintained gains up to 2 years later, despite chronicities of several years ( Barlow et al., 1984 ; Barlow, Rapee, & Brown, in press; Blowers, Cobb, & Mathews, 1987 ; Borkovec & Mathews, 1988 ; Borkovec et al., 1987 ; Butler, Cullington, Hibbert, Klimes, & Gelder, 1987 ; Butler, Fennell, Robson, & Gelder, 1991 ). These initial studies have been disappointing, however, in two ways: The degree of clinically significant change has not been large, and comparisons among various therapies or elements have been generally nonsignificant. Thus, research has yet to rule out rival hypotheses concerning the active ingredients of treatments for GAD, including the crucial possibility that nonspecific factors account for the observed gains. In the present study, we attempted to increase the efficacy of a behavioral and a cognitive—behavioral Journal of Consulting and Clinical Psychology © 1993 by the American Psychological Association August 1993 Vol. 61, No. 4, 611-619 For personal use only--not for distribution. Page 1 of 1410/30/2000http://spider.apa.org/ftdocs/ccp/1993/august/ccp614611.htmltreatment by certain technique emphases based on theory and recent basic research findings regarding the nature of GAD. Moreover, an attempt was made to conduct a controlled outcome investigation with a methodology and design (contrasting applied relaxation [AR], cognitive—behavioral therapy [CBT], and nondirective therapy [ND]) that would hopefully allow unambiguous elimination of two of the most likely rival hypotheses in prior studies: nonspecific factors and the relaxation training component. As does all anxious experience ( Lang, 1968 ), the anxiety of a GAD client involves a process of interacting systems (attentional, conceptual, imaginal, physiological, affective, and behavioral) that unfolds over time in continual response to a constantly changing environment. Several features, however, may distinguish the process of GAD from those of other anxiety disorders (cf. Borkovec, Shadick, & Hopkins, 1991 ): (a) less obvious environmental triggers of the anxiety or behavioral avoidance to them; (b) preattentive bias to multiple threat cues with rapid cognitive avoidance on detection; (c) predominance of verbal-linguistic worry, which may function to avoid aspects of anxious experience by suppressing fear-related imagery, somatic activation, and emotional processing; and (d) unusual somatic features that include inhibition of the sympathetic autonomic system, a restriction in the range of its variability, and a resulting physiological inflexibility both at rest and when challenged. GAD clients are thus hypothetically stuck in chronic, habitual modes of multisystem interactive responding, with each occurrence of the process functioning as a defensive reaction to threat and resulting in a sequence of anxious responses that acquires greater habit strength from repetition. These observations suggest some useful emphases in the relaxation and cognitive—behavioral treatments of GAD: (a) the central importance of self-observation in detecting the initiation of the anxiety process earlier in its interactive sequence; (b) particular therapeutic attention to chains of worrisome thinking as one of the most crucial early cues for coping deployments; (c) the necessity of clinically thorough relaxation training (e.g., applied relaxation training; Ost, 1987 ); (d) the usefulness of multiple relaxation methods that target different response-system levels and increase flexibility, including teaching a generalized letting-go response to illusory thoughts and aversive images about the past or future; and (e) frequent in-session practice of all of these emphases to facilitate early cue detection and the strengthening of coping responses. The possible function of worry for escaping anxiety-provoking imagery to avoid somatic anxiety also suggests the importance of imagery exposures to anxiety-related internal and external cues. The pervasiveness of worrisome thinking and its typical catastrophic predictions suggests the particular valueof cognitive therapy. The habitual nature of interactive anxiety process suggests the need for frequent rehearsal of cognitive and relaxation coping skills in response to detected cues to strengthen new habits. Consequently, a cognitive—behavioral treatment that includes AR, self-control desensitization that involves accessing anxiety-related images and worrisome thoughts and practicing coping skills in response to them, and cognitive therapy used along with
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