Tweaking CBT to boost outcomes in GAD

Relaxation-induced anxiety

Relaxation training often is incorporated in treatment packages for GAD. Yet, it’s possible that one reason CBT is only modestly effective for GAD is because of relaxation-induced anxiety (RIA), an understudied phenomenon defined as a paradoxical increase in the physiological, behavioral, and cognitive aspects of anxiety when a person tries to relax.

“It has been theorized that individuals who are especially concerned with maintaining control over physical and psychological processes find relaxation vulnerable, unpleasant, and activating. Thus, discomfort with perceived lack of control during relaxed moments – an inability to let go – may result in unsought increase in anxiety during therapeutic attempts at relaxation,” according to Michelle G. Newman, PhD, professor of psychology at Penn State.

She presented a secondary analysis of a published randomized clinical trial she coauthored (J Consult Clin Psychol. 2002 Apr;70[2]:288-98) in which 41 participants with GAD were assigned to CBT with relaxation therapy using standard progressive muscle relaxation techniques or to self-control desensitization. Relaxation therapy and relaxation-induced anxiety ratings were recorded at each session. Outcomes were assessed post-treatment and at 6, 12, and 24 months of follow-up using the Penn State Worry Questionnaire, the State-Trait Anxiety Inventory, the Hamilton Anxiety Rating Scale, and the Clinician Severity Rating for GAD symptoms. In addition, immediately after each in-session relaxation practice, patients were asked to rate on a 9-point scale how much they noticed an increase in anxiety during the relaxation session.

All subjects improved significantly, but those with a lower peak RIA – defined as the highest level of RIA experienced in any of the 14 treatment sessions – had significantly fewer GAD symptoms at the end of therapy as well as at 2-year follow-up. Peak RIA was unrelated to baseline GAD symptom severity or change over time in anxiety symptoms. However, patients whose peak RIA occurred during the last several treatment sessions showed less improvement in GAD symptoms at the conclusion of treatment than those whose peak came earlier.

The clinical implications of these findings are that therapists who use progressive muscle relaxation in the treatment of GAD should assess RIA at the conclusion of every session, and if a patient reports moderate or higher RIA, the duration of the relaxation training portion of therapy should not be shortened until after several consecutive sessions of lower RIA have been reported, according to Dr. Newman.

Emotion regulation therapy

Megan E. Renna brought attendees up to speed on emotion regulation therapy (ERT), a third wave variant of CBT that incorporates principles from more traditional CBT, such as skills training and exposure, supplemented by teaching emotion regulation skills. Those skills include the development of present moment awareness and cultivation of compassion. Both are grounded in research on motivational and regulatory learning mechanisms related to threat vs. safety and reward versus loss.

As detailed in a recent review article for which she was first author (Front Psychol. 2017 Feb 6;8:98), ERT is a manualized, mechanism-targeted treatment for what she termed “distress disorders”; namely, GAD and major depressive disorder, which are highly comorbid, share key underlying temperamental features, and for whom adequate therapeutic success is all too often elusive. ERT appears to be particularly useful during the emerging adulthood years and across a broad range of ethnic and racial patients, according to Ms. Renna, a PhD student in clinical psychology at Hunter College in New York.

The efficacy of the original 20-session, individual therapy version of ERT was established in a study of 20 GAD patients, half of whom also had major depression (Depress Anxiety. 2015 Aug;32[8]:614-23). But Ms. Renna said ERT’s developers – Douglas S. Mennin, PhD, of Hunter College, and David M. Fresco, PhD, of Kent State (Ohio) University, are interested in determining the minimum effective therapeutic dose of ERT. They have conducted an open randomized trial of a 16-session version of ERT in which the results proved similar to those seen with 20 sessions. Now they’re carrying out a study of 8 vs. 16 sessions. The study is ongoing, but at first look, the results with 8 sessions of ERT appear similar to 16, Ms. Renna said.

None of the speakers reported having any financial conflicts of interest.