CBT for Generalised Anxiety Disorder

Introduction

Brief overview of generalised anxiety disorder (GAD)

Generalised Anxiety Disorder (GAD) is an anxiety disorder recognized in both major manuals clinicians use to diagnose mental health disorders the DSM-V and the ICD-10. GAD shares aspects of other anxiety disorders, such as excessive worrying, cognitive biases, and anxious anticipation, but it is distinguished from others by a heightened intolerance of uncertainty and a near-constant experience of anxiety.¹

Also specific to GAD, the themes of concern are usually about a range of different themes related to daily life, such as work, health, finances, and family. While these themes of concern often mirror those of the general population, individuals with GAD worry about these constantly - even when there's no real ‘need’ to be concerned - and they often envision catastrophic outcomes. This excessive worrying can be extremely difficult to control and can lead to restlessness, a general feeling of uneasiness, irritability, a loss of appetite, muscle pains, and difficulty with sleep and concentration.^1,2 It is, therefore, quite debilitating.

Furthermore, to avoid the worries and associated symptoms, sufferers may develop coping behaviours like:

• Frequently seeking reassurance
• Avoiding events that trigger anxiety
• Spending a lot of time mentally preparing for stressful situations in the future.¹

However, while these behaviours can offer short-term relief, they inadvertently feed into the condition, trapping individuals in a cycle which can lead to a restricted lifestyle. The following complications can occur from GAD symptoms and the associated coping strategies:³

• Depression
• Insomnia
• Drug/alcohol abuse
• Social isolation
• Impaired relationships
• Gastrointestinal problems
• Problems functioning at school/work
• Reduced quality of life

CBT for GAD – Overview

This is why Cognitive Behavioural Therapy (CBT) can be very useful because not only does this therapeutic technique target thoughts (cognition) but it also targets unhelpful behaviours through behaviour modification. In CBT, you and the practitioner work together to establish connections between these thoughts, feelings, behaviours.

This newfound understanding is put into action by forming hypotheses about your worries, which are then tested in real-life situations. Combined with problem-solving and relaxation techniques, you gradually expose yourself to events that trigger anxiety. In essence, CBT works to empower individuals to change thoughts and behaviours that sustain GAD, enabling them to lead a more unrestricted life with reduced worry and anxiety.⁴

So, what does CBT consist of, you might ask? For GAD, there are 3 main domains explored by the practitioner and patient:

1. Psychoeducation
2. Cognitive restructuring
3. Relaxation techniques and skills training

In each of these domains, there are different techniques employed by the therapist to achieve their aim. A therapist may emphasise the importance of one of these domains and techniques over another, depending on their own clinical judgement.⁴ 

Psychoeducation

Psychoeducation is often one of the first techniques used in therapy. However, it is likely to occur throughout the process. It serves several important functions. Firstly, it can be very reassuring knowing that others are struggling with similar issues and that there are reasons why you are struggling. Secondly, it helps you understand the rationale for parts of the treatment process and set realistic expectations, both of which can be highly motivating. Thirdly, it is essential to learn about the interrelationship between thoughts, behaviours and emotions (AKA the cognitive triangle) as this is one of the fundamental parts of the treatment. Other techniques that follow are built off from your understanding of this cognitive triangle.

Cognitive restructuring – identifying and overcoming cognitive biases

Step 1:  Identifying cognitive biases and their effect

The overall aim of cognitive structuring is to alter your anxious thoughts to ones that are more balanced or realistic. These are then used to guide behaviour. Therefore, it is based on the premise that GAD is partly a result of interpretations of events that are not realistic and that these interpretations arise from cognitive biases, which can be disrupted.

Cognitive biases are automatic habits in our thinking that simplify information as a way for our brain to deal with the enormity of information it receives every second. It often involves interpreting information based on our existing beliefs and experiences in a way that doesn’t follow the rules of logic and probability. It, therefore, distorts how we interpret information and make decisions.⁵

While cognitive biases can serve a purpose, individuals with Generalised Anxiety Disorder (GAD) often harbour specific biases that contribute to and perpetuate their condition. For instance, a common bias is the tendency to believe that the most catastrophic outcome of a situation is the only conceivable result.

In therapy sessions, your therapist will assist you in recognizing these biases through questioning and role-playing exercises. Together, you will explore situations linked to these biases, delving into the thoughts and emotions that arise.

Outside of the sessions, you will be encouraged to independently monitor these thoughts and feelings, examining their associations with different situations and understanding the role that biases play. This process may also involve creating a list of fears, ranked by the level of worry they induce, which can later inform systematic exposure exercises.

Step 2: Alternative thought creation

After helping you to notice these thinking patterns, the therapist will help you imagine more balanced interpretations and predictions, such as more realistic outcomes to situations. You will then work to dispute these distorted thoughts as they arise and actively replace them with more balanced ones, reducing anxiety and worry.

You will work together to devise experiments to observe these thoughts and feelings in action, test the validity of biases and practise cognitive reconstruction. You may be instructed to write notes into a thought record, which could look something like this.⁶

Step 3: Systematic exposure  

Arguably, the most important part of CBT is exposing yourself to the scenarios that cause the most worry outside of the session. A common coping mechanism learnt by GAD sufferers is avoidance of scenarios that cause worry, which only perpetuates the condition. Systematic exposure aims to unlearn this behaviour by confronting your fears in a gradual, structured, and mindful manner, starting with the scenarios that cause minimal anxiety to the ones that cause the most (based on the list of worries created at the start of treatment).

For each exposure, notes are taken on what kind of thoughts and feelings come up, as well as the outcome of the scenario. This information is then reported back to the therapist, who will discuss it during the session to help put things into perspective. This essentially tests the validity of anxious vs reconstructed thoughts and can demonstrate that your feared outcomes are less likely to occur than you initially thought. It can also lead to an increased feeling of control over your anxious responses.^2,5

In addition to exposure therapies, other behavioural techniques may be used in cognitive restructuring, such as opposite action and behavioural activation.²

Relaxation techniques and skills training

The aim of relaxation techniques is multifaceted. Firstly, they can provide immediate relief to the discomfort associated with anxiety. Secondly, they can provide a sense of control over anxiety’s effects. Thirdly, they can also disrupt the cognitive biases that arise when anxiety levels increase. When anxiety levels increase, there is increased attention towards potential threats, and this can bias your brain to perceive a threat when it isn’t there or greatly overestimate it. Left unabated, this can start a vicious cycle of anxiety. Relaxation techniques aim to interrupt this cycle.³ This can then allow you to think more clearly and more easily implement what you have learnt through cognitive restructuring.

The most common relaxation techniques include:

• Progressive muscle relaxation (progressively tensing then relaxing muscle groups)
• Meditation
• Deep breathing

However, other relaxation techniques may be explored, and you can choose the most preferred techniques.

Other techniques

The techniques discussed so far are the main ones explored in CBT. However, depending on the training of the practitioner, their own clinical judgement and their own preferences, other techniques may be used. Many of these other techniques build skills that can help remedy some of the issues from GAD, such as difficulty in making decisions, organisation and maintaining relationships.

These options include:

• Time management and organisational skills
• Problem-solving
• Social skills training
• Mindfulness
• Emotional regulation

Effectiveness and complications

There is a large body of evidence showing that CBT consistently reduces the most distressing symptoms of GAD, such as excessive worry, muscle tension, restlessness and unhealthy coping behaviours. Long-term studies have shown that these reductions are maintained within and after 12 months following the treatment’s completion.⁷

However, not everybody responds well to CBT treatment for a variety of reasons at an individual, organisational, and systemic level, including:⁸

• Presence of other mental health conditions
• Substance abuse
• Inflexible work schedules
• Complex trauma
• Learning difficulties
• Cultural backgrounds
• Relationship between patient and practitioner
• The overall motivation for treatment

Ultimately, CBT is not suitable for everyone. This makes guidance from a practitioner trained in a variety of therapeutic methods highly valuable. Clinical psychologists are equipped with diverse training and can tailor approaches to individual circumstances and preferences, often blending multiple methods. However, these professionals typically focus on more severe cases. Additionally, medication may also be needed to get the most out of therapy, and seeing a psychiatrist or your GP may be a necessary step.

It is also important to remember that what occurs outside of a therapy room can be just as important, if not more important. The things you learn in sessions need to be implemented in a sustainable way, and things like regular exercise and developing a strong support network are crucial to maintaining mental health over the long term.

Summary and FAQs

GAD is characterised by excessive worrying about a range of things related to daily life, often leading to a range of debilitating symptoms and complications. Coping mechanisms, such as seeking reassurance and avoidance, inadvertently perpetuate the condition and contribute to a restricted lifestyle. Cognitive Behavioural Therapy (CBT) emerges as a transformative approach, empowering individuals to challenge maladaptive thought patterns and behaviours. Through enhanced understanding, mindful exposure, and practical skills, CBT aims to break the cycle of worry, fostering a lifeless inhibited by anxiety. The goal is to provide individuals with the tools to alter thought patterns, ultimately leading to a more liberated and fulfilling existence. However, CBT is not always effective for a variety of reasons, and other treatments or combined approaches may be more effective.

FAQ’s

1. How long does CBT treatment last?

An individual session will usually last around an hour. The number of sessions can vary, but usually lasts between 10 and 20 sessions with most people a reporting significant reduction in symptoms after 10 sessions.²

1. Who performs CBT?

Psychologists, psychiatrists, psychotherapists, and counsellors may be trained in using CBT for a range of mental health disorders, including GAD. CBT can also be done by yourself; however, this is only recommended for mild symptoms.²