Emotion Regulation Therapy for Generalized Anxiety Disorder

doi:10.1016/j.cbpra.2013.02.001

Cognitive and Behavioral Practice

Volume 20, Issue 3, August 2013, Pages 282-300

https://doi.org/10.1016/j.cbpra.2013.02.001 Get rights and content

Abstract

Despite the success of cognitive behavioral therapies (CBT) for emotional disorders, a sizable subgroup of patients with complex clinical presentations, such as patients with generalized anxiety disorder, fails to evidence adequate treatment response. Emotion Regulation Therapy (ERT) integrates facets of traditional and contemporary CBTs, mindfulness, and emotion-focused interventions within a framework that reflects basic and translational findings in affect science. Specifically, ERT is a mechanism-targeted intervention focusing on patterns of motivational dysfunction while cultivating emotion regulation skills. Open and randomized controlled psychotherapy trials have demonstrated considerable preliminary evidence for the utility of this approach as well as for the underlying proposed mechanisms. This article provides an illustration of ERT through the case of “William.” In particular, this article includes a case-conceptualization of William from an ERT perspective while describing the flow and progression of the ERT treatment approach.

Section snippets

Affect Science Approach to Emotion Function and Dysfunction

Drawing from a perspective that emphasizes the analysis of emotions from normative to disordered functioning, ERT delineates three main facets of basic emotional functioning: (a) motivational mechanisms, reflecting the functional and directional properties of an emotional response tendency; (b) regulatory mechanisms, reflecting the altering of response trajectories to be more congruent with contextual demands and constraints as well as one’s personal values or goals, and (c) contextual learning

Benefits in Contrast to Standard CBT for GAD

ERT is our effort to simultaneously remain true to CBT core principles while also incorporating theory and evidence from the burgeoning basic and translational science of emotions in hopes of improving our understanding and treatment of GAD while also aligning with NIMH priorities such as the Research Domain Criteria (Sanislow et al., 2010). Thus, we view ERT as a member of the family of CBTs and as one way to understand and implement the principles common to many of the successful CBT packages

Research Findings

To date, the efficacy of ERT has been demonstrated in a recently concluded NIMH-funded open trial (OT; N = 19) and a randomized clinical trial (RCT; N = 60; Mennin and Fresco, 2011, Mennin et al., 2012). ERT was very well tolerated by clients, as evidenced by low rates of attrition in the course of treatment. For instance, 18 of 19 OT patients and 26 of 30 RCT patients completed all 20 sessions of treatment. In terms of clinical outcomes, OT patients evidenced reductions in both clinician-assessed

Specific Assessment Strategies

When determining the appropriateness of a case for ERT, a combination of nomothetic and idiographic assessment techniques is utilized. Although like most behavior therapists we view diagnostic categorizations as less relevant, we begin with a lifetime diagnostic interview such as the Structured Clinical Interview for DSM-IV (First et al., 2002) or Anxiety Disorders Interview Schedule–Lifetime, Fourth Edition (Di Nardo, Brown, & Barlow, 1994) to determine the presence of a GAD diagnosis as well

Clinical Considerations

As noted above, the ERT model adopts the affect science perspective that, although not always productive in every given moment, emotions are adaptive and have survival value in that they are powerful signals for both approach and avoidance motivations. However, because of deficits in flexibly attending to these emotional states, individuals suffering from GAD instead utilize a preponderance of more elaborative maladaptive reactive responses (i.e., worry, rumination, self-criticism). By the time

Future Directions

As compared to other mindfulness-informed CBTs (Ellard et al., 2010, Hayes et al., 1999, Hayes-Skelton et al., 2013, Jacobson et al., 2001, Linehan, 1993, Roemer et al., 2008, Segal et al., 2002), ERT is a relative newcomer to the world of evidence-based treatments. Despite the success of CBT, a sizable subgroup of patients with complex clinical presentations such as GAD do not have adequate treatment response. To address these refractory conditions, there has been a growing interest in

References (98)

M.M. Antony et al.
Dimensions of perfectionism across the anxiety disorders
Behaviour Research and Therapy
(1998)
M. Bar
A cognitive neuroscience hypothesis of mood and depression
Trends in Cognitive Sciences
(2009)
A. Butler et al.
The empirical status of cognitive-behavioral therapy: A review of meta-analyses
Clinical Psychology Review
(2006)
J. Cassidy et al.
Generalized anxiety disorder: Connections with self-reported attachment
Behavior Therapy
(2009)
J.R. Cougle et al.
Excessive reassurance seeking and anxiety pathology: Tests of incremental associations and directionality
Journal of Anxiety Disorders
(2012)
M.G. Craske et al.
Optimizing inhibitory learning during exposure therapy
Behaviour Research and Therapy
(2008)
R. Gould et al.
Cognitive behavioral and pharmacological treatment of generalized anxiety disorder: A preliminary meta-analysis
Behavior Therapy
(1997)
S.A. Hayes-Skelton et al.
An acceptance-based behavioral therapy for individuals with generalized anxiety disorder
Cognitive and Behavioral Practice
(2013)
J. Hoyer et al.
Psychotherapy for generalized anxiety disorder: Don’t worry, it works!
Psychiatric Clinics of North America
(2009)
M.M. Klenk et al.
Regulatory focus and anxiety: A self-regulatory model of GAD-depression comorbidity
Personality and Individual Differences
(2011)

D.S. Mennin et al.

Preliminary evidence for an emotion dysregulation model of generalized anxiety disorder

Behaviour Research and Therapy

(2005)

D.S. Mennin et al.

Delineating components of emotion and its dysregulation in anxiety and mood psychopathology

Behavior Therapy

(2007)

M.G. Newman et al.

A novel theory of experiential avoidance in generalized anxiety disorder: A review and synthesis of research supporting a contrast avoidance model of worry

Clinical Psychology Review

(2011)

M. Robichaud

Cognitive behavioral therapy targeting intolerance of uncertainty: Application to a clinical case of generalized anxiety disorder

Cognitive and Behavioral Practice

(2013)

K. Salters-Pedneault et al.

An experimental investigation of the effect of worry on responses to a discrimination learning task

Behavior Therapy

(2008)

J. Stöber et al.

Weekly assessment of worry: An adaptation of the Penn State Worry Questionnaire for monitoring changes during treatment

Behaviour Research and Therapy

(1998)

J. Teasdale

Emotional processing, three modes of mind and the prevention of relapse in depression

Behaviour Research and Therapy

(1999)

A. Baddeley

Working memory: Theories, models, and controversies

Annual Review of Psychology

(2012)

H. Balzac

The comedie humaine

(1897)

A.T. Beck et al.

Cognitive therapy of depression: A treatment manual

(1979)

A.T. Beck et al.

Beck Depression Inventory Manual

(1996)

T.D. Borkovec

The nature, functions, and origins of worry

T.D. Borkovec et al.

Avoidance theory of worry and generalized anxiety disorder

T.D. Borkovec et al.

A component analysis of cognitive-behavioral therapy for generalized anxiety disorder and the role of interpersonal problems

Journal of Consulting and Clinical Psychology

(2002)

T.D. Borkovec et al.

Psychotherapy for generalized anxiety disorder

The Journal of Clinical Psychiatry

(2001)

T. Borkovec et al.

Generalized anxiety disorder: Bringing cognitive behavioral therapy into the valued present

M.E. Bouton et al.

A modern learning theory perspective on the etiology of panic disorder

Psychological Review

(2001)

J.F. Brosschot et al.

Worry, perserverative thinking and health

L. Campbell-Sills et al.

Psychometric evaluation of the behavioral inhibition/behavioral activation scales in a large sample of outpatients with anxiety and mood disorders

Psychological Assessment

(2004)

B.F. Chorpita et al.

The structure of negative emotions in a clinical sample of children and adolescents

Journal of Abnormal Psychology

(1998)

R.J. Davidson

Affective style and mood disorders: Perspectives from affective neuroscience

Cognition and Emotion

(1998)

P.A. Di Nardo et al.

Anxiety Disorders Interview Schedule for DSM-IV: Lifetime version (ADIS-IV-L)

(1994)

M.J. Dugas et al.

Cognitive-behavioral treatment for generalized anxiety disorder: From science to practice

(2007)

K.K. Ellard et al.

Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders: Protocol Development and Initial Outcome Data

Cognitive and Behavioral Practice

(2010)

R. Elliott et al.

Learning emotion-focused therapy: The process-experiential approach to change

(2004)

A. Etkin et al.

Failure of anterior cingulate activation and connectivity with the amygdala during implicit regulation of emotional processing in generalized anxiety disorder

The American Journal of Psychiatry

(2010)

A. Etkin et al.

Common abnormalities and disorder-specific compensation during implicit regulation of emotional processing in generalized anxiety and major depressive disorders

The American Journal of Psychiatry

(2011)

C.B. Ferster

A functional analysis of depression

American Psychologist

(1973)

M.B. First et al.

Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition With Psychotic Screen (SCID-I/P W/PSY SCREEN) New York, NY: Biometrics Research, New York State Psychiatric Institute

(2002)

E.B. Foa et al.

Emotional processing of fear: Exposure to corrective information

Psychological Bulletin

(1986)

B.L. Fredrickson

The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions

American Psychologist

(2001)

D.M. Fresco et al.

Distinct and overlapping features of rumination and worry: The relationship of cognitive production to negative affective states

Cognitive Therapy and Research

(2002)

D.M. Fresco et al.

Relationship of posttreatment decentering and cognitive reactivity to relapse in major depression

Journal of Consulting and Clinical Psychology

(2007)

N.H. Frijda

The emotions

(1986)

P. Gilbert

An introduction to compassion focused therapy in cognitive behavior therapy

International Journal of Cognitive Therapy

(2010)

J.A. Gray et al.

The neuropsychology of anxiety: An enquiry into the functions of the septo-hippocampal system

(2000)

L.S. Greenberg

Integrating an emotion-focused approach to treatment into psychotherapy integration

Journal of Psychotherapy Integration

(2002)

J. Gross

Emotion regulation: Affective, cognitive, and social consequences

Psychophysiology

(2002)

J.J. Gross et al.

Emotion regulation: Conceptual foundations

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¹: Video patients/clients are portrayed by actors.

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Contains Video1Emotion Regulation Therapy for Generalized Anxiety Disorder

Abstract

Section snippets

Affect Science Approach to Emotion Function and Dysfunction

Benefits in Contrast to Standard CBT for GAD

Research Findings

Specific Assessment Strategies

Clinical Considerations

Future Directions

Behaviour Research and Therapy

Trends in Cognitive Sciences

Clinical Psychology Review

Behavior Therapy

Journal of Anxiety Disorders

Behaviour Research and Therapy

Behavior Therapy

Cognitive and Behavioral Practice

Psychiatric Clinics of North America

Personality and Individual Differences

Behaviour Research and Therapy

Behavior Therapy

Clinical Psychology Review

Cognitive and Behavioral Practice

Behavior Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Working memory: Theories, models, and controversies

Annual Review of Psychology

The comedie humaine

Cognitive therapy of depression: A treatment manual

Beck Depression Inventory Manual

The nature, functions, and origins of worry

Avoidance theory of worry and generalized anxiety disorder

A component analysis of cognitive-behavioral therapy for generalized anxiety disorder and the role of interpersonal problems

Journal of Consulting and Clinical Psychology

Psychotherapy for generalized anxiety disorder

The Journal of Clinical Psychiatry

Generalized anxiety disorder: Bringing cognitive behavioral therapy into the valued present

A modern learning theory perspective on the etiology of panic disorder

Psychological Review

Worry, perserverative thinking and health

Psychometric evaluation of the behavioral inhibition/behavioral activation scales in a large sample of outpatients with anxiety and mood disorders

Psychological Assessment

The structure of negative emotions in a clinical sample of children and adolescents

Journal of Abnormal Psychology

Affective style and mood disorders: Perspectives from affective neuroscience

Cognition and Emotion

Anxiety Disorders Interview Schedule for DSM-IV: Lifetime version (ADIS-IV-L)

Cognitive-behavioral treatment for generalized anxiety disorder: From science to practice

Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders: Protocol Development and Initial Outcome Data

Cognitive and Behavioral Practice

Learning emotion-focused therapy: The process-experiential approach to change

Failure of anterior cingulate activation and connectivity with the amygdala during implicit regulation of emotional processing in generalized anxiety disorder

The American Journal of Psychiatry

Common abnormalities and disorder-specific compensation during implicit regulation of emotional processing in generalized anxiety and major depressive disorders

The American Journal of Psychiatry

A functional analysis of depression

American Psychologist

Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition With Psychotic Screen (SCID-I/P W/PSY SCREEN) New York, NY: Biometrics Research, New York State Psychiatric Institute

Emotional processing of fear: Exposure to corrective information

Psychological Bulletin

The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions

American Psychologist

Distinct and overlapping features of rumination and worry: The relationship of cognitive production to negative affective states

Cognitive Therapy and Research

Relationship of posttreatment decentering and cognitive reactivity to relapse in major depression

Journal of Consulting and Clinical Psychology

The emotions

An introduction to compassion focused therapy in cognitive behavior therapy

International Journal of Cognitive Therapy

The neuropsychology of anxiety: An enquiry into the functions of the septo-hippocampal system

Integrating an emotion-focused approach to treatment into psychotherapy integration

Journal of Psychotherapy Integration

Emotion regulation: Affective, cognitive, and social consequences

Psychophysiology

Emotion regulation: Conceptual foundations

Contains Video¹
Emotion Regulation Therapy for Generalized Anxiety Disorder