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      Reducing behavioral avoidance with internet-delivered cognitive behavior therapy for generalized anxiety disorder

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          Abstract

          Recent research has sought to identify maladaptive behaviors that are associated with generalized anxiety disorder (GAD). Although maladaptive behaviors may contribute to the maintenance of the disorder, little is known about how these behaviors change during the course of cognitive behavior therapy and whether such changes relate to treatment outcomes. This study examined changes in maladaptive behaviors, symptoms of GAD and depression, and disability across internet-based cognitive behavior therapy (iCBT) for GAD in two large clinical samples (N = 206 and 298). Assessments were completed at pre and post-treatment. Significant reductions in patients' maladaptive behaviors (WBI), GAD and depression severity (GAD-7 and PHQ-9), and disability (WHODAS-II) were observed following iCBT. Reductions in maladaptive behaviors predicted post-treatment GAD symptom severity after controlling for pre-treatment GAD symptom severity and reductions in depression and disability. Findings provide further support for the importance of maladaptive behaviors in contemporary conceptualizations of GAD and highlight the need for experimental investigations to examine the possible causal relationships between maladaptive behaviors and GAD.

          Highlights

          • •

            Maladaptive behaviors in generalized anxiety disorder (GAD) are not well understood.

          • •

            Behavioral avoidance may contribute to the maintenance of GAD.

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            Maladaptive behaviors reduced following online cognitive behavior therapy for GAD.

          • •

            Reductions in avoidant behaviors predicted post-treatment GAD symptom severity.

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          Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample.

          Timothy A Brown, Laura A Campbell, Cassandra L. Lehman … (2001)
          The comorbidity of current and lifetime DSM-IV anxiety and mood disorders was examined in 1,127 outpatients who were assessed with the Anxiety Disorders Interview Schedule for DSM-IV: Lifetime version (ADIS-IV-L). The current and lifetime prevalence of additional Axis I disorders in principal anxiety and mood disorders was found to be 57% and 81%, respectively. The principal diagnostic categories associated with the highest comorbidity rates were mood disorders, posttraumatic stress disorder (PTSD), and generalized anxiety disorder (GAD). A high rate of lifetime comorbidity was found between the anxiety and mood disorders; the lifetime association with mood disorders was particularly strong for PTSD, GAD, obsessive-compulsive disorder, and social phobia. The findings are discussed in regard to their implications for the classification of emotional disorders.
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            Validation of the PHQ-9 in a psychiatric sample.

            C. MARY BEARD, K. J. HSÜ, L Rifkin … (2016)
            The PHQ-9 was originally developed as a screener for depression in primary care and is commonly used in medical settings. However, surprisingly little is known about its psychometric properties and utility as a severity measure in psychiatric populations. We examined the full range of psychometric properties of the PHQ-9 in patients with a range of psychiatric disorders (i.e., mood, anxiety, personality, psychotic).
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              Internet Treatment for Generalized Anxiety Disorder: A Randomized Controlled Trial Comparing Clinician vs. Technician Assistance

              Emma Robinson, Nickolai Titov, Gavin Andrews … (2010)
              Background Internet-based cognitive behavioural therapy (iCBT) for generalized anxiety disorder (GAD) has been shown to be effective when guided by a clinician. The present study sought to replicate this finding, and determine whether support from a technician is as effective as guidance from a clinician. Method Randomized controlled non-inferiority trial comparing three groups: Clinician-assisted vs. technician-assisted vs. delayed treatment. Community-based volunteers applied to the VirtualClinic (www.virtualclinic.org.au) research program and 150 participants with GAD were randomized. Participants in the clinician- and technician-assisted groups received access to an iCBT program for GAD comprising six online lessons, weekly homework assignments, and weekly supportive contact over a treatment period of 10 weeks. Participants in the clinician-assisted group also received access to a moderated online discussion forum. The main outcome measures were the Penn State Worry Questionnaire (PSWQ) and the Generalized Anxiety Disorder-7 Item (GAD-7). Completion rates were high, and both treatment groups reduced scores on the PSWQ (p<0.001) and GAD-7 (p<0.001) compared to the delayed treatment group, but did not differ from each other. Within group effect sizes on the PSWQ were 1.16 and 1.07 for the clinician- and technician-assisted groups, respectively, and on the GAD-7 were 1.55 and 1.73, respectively. At 3 month follow-up participants in both treatment groups had sustained the gains made at post-treatment. Participants in the clinician-assisted group had made further gains on the PSWQ. Approximately 81 minutes of clinician time and 75 minutes of technician time were required per participant during the 10 week treatment program. Conclusions Both clinician- and technician-assisted treatment resulted in large effect sizes and clinically significant improvements comparable to those associated with face-to-face treatment, while a delayed treatment/control group did not improve. These results provide support for large scale trials to determine the clinical effectiveness and acceptability of technician-assisted iCBT programs for GAD. This form of treatment has potential to increase the capacity of existing mental health services. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12609000563268
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                Author and article information

                Contributors
                Alison E.J. Mahoney
                Jill M. Newby
                Megan J. Hobbs
                Alishia D. Williams
                Gavin Andrews
                Journal
                Journal ID (nlm-ta): Internet Interv
                Journal ID (iso-abbrev): Internet Interv
                Title: Internet Interventions
                Publisher: Elsevier
                ISSN (Electronic): 2214-7829
                Publication date PMC-release: 10 November 2017
                Publication date Collection: March 2019
                Publication date (Electronic): 10 November 2017
                Volume: 15
                Pages: 105-109
                Affiliations
                [a ]Clinical Research Unit for Anxiety and Depression, University of New South Wales at St. Vincent's Hospital, Level 4 O'Brien Centre, 394-404 Victoria Street, Darlinghurst, NSW 2010, Australia
                [b ]School of Psychology, University of New South Wales, Sydney, NSW 2052, Australia
                [c ]Department of Clinical and Health Psychology, Utrecht University, Domplein 29, 3512 JE Utrecht, The Netherlands
                Author notes
                [* ]Corresponding author. alison.mahoney@ 123456svha.org.au
                Article
                Publisher ID: S2214-7829(17)30054-4
                DOI: 10.1016/j.invent.2017.11.004
                PMC ID: 6371407
                SO-VID: a186ecca-0c79-47fb-ac71-eab033809b56
                Copyright © © 2017 The Authors
                License:

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                Date received : 23 May 2017
                Date revision received : 1 November 2017
                Date accepted : 1 November 2017
                Categories
                Subject: Full length Article

                Keywords: generalized anxiety disorder,cognitive behavior therapy,avoidance,safety behavior
                Data availability:
                Keywords: generalized anxiety disorder, cognitive behavior therapy, avoidance, safety behavior

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