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Behaviour Research and Therapy 41 (2003) 633646 www.elsevier.com/locate/brat

Cognitive therapy versus applied relaxation as treatment ofgeneralized anxiety disorder

A. Arntz

Department of Medical, Clinical and Experimental Psychology, University of Maastricht, P.O. Box 616,

NL-6200 MD Maastricht, The Netherlands

Accepted 14 March 2002

Abstract

Cognitive therapy (CT) and applied relaxation (AR) as treatments of generalized anxiety disorder (GAD)were compared in a sample of 45 patients of a community mental health center, randomly allocated tocondition. Patients were assessed before and after a 12-session treatment, and at one and six months follow-ups. There was a 20% drop out from CT and 15% from AR (NS), with some drop outs being considerablyimproved. Both completers and intention-to-treat analyses revealed that both treatments were effective (ESs

of composite and specific measures ranging from 0.53 to 1.14). At one-month follow-up AR tended to dobetter than CT, with CT catching up with AR at six months. Recovery rates and proportions of patientsshowing reliable change were comparable to other studies on AR and CT, with 55% of CT and 53.3% ofAR patients recovered on the STAI-trait at six-month follow-up. These results confirm that both CT andAR are effective treatments for GAD, and also that there is still room for improvement. 2003 Elsevier Science Ltd. All rights reserved.

1. Introduction

Although a very common and chronic problem in the general population (lifetime prevalence4.16.6%, Blazer, Hughes, George, Swartz, & Boyer, 1991; Kessler et al., 1994), generalizedanxiety disorder (GAD) is not so frequently seen in mental health centers (e.g. approx. 4.3% ofthe patients from our center have GAD as a first diagnosis). Despite a relatively low prevalenceof GAD at our center, we decided thirteen years ago to start a clinical trial, comparing what thenseemed to be two of the most promising treatments for GAD, applied relaxation (AR) and cogni-

Tel.: +31-43-388-1225; fax: +31-43-388-4155.E-mail address: [email protected] (A. Arntz).

0005-7967/03/$ - see front matter 2003 Elsevier Science Ltd. All rights reserved.doi:10.1016/S0005-7967(02)00045-1


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634 A. Arntz / Behaviour Research and Therapy 41 (2003) 633646

tive therapy (CT). In the meantime, much more has become clear about the effects of varioustreatments for GAD.

Several studies have compared CT and cognitive-behavior therapy (CBT), based on the workof Beck and Emery (1985) with behavior therapy (BT) approaches (such as anxiety managementtraining). In general, C(B)T was more effective than BT, especially in the long run (Butler, Fen-nell, Robson, & Gelder, 1991; Durham & Turvey, 1987; Durham, Murphy, Allan, Richard, Treliv-ing, & Fenton, 1994). CBT has also been compared to benzodiazepines, and proved to be moreeffective both in the short and in the long term (Power, Jerrom, Simpson, Mitchell, & Swanson,1989; Power, Simpson, Swanson, & Wallace, 1990). A recently developed CBT package specifi-cally focussing at worrying was only compared to a waitlist condition (Ladouceur et al., 2000).AR, a treatment approach developed by several workers (Bernstein & Borkovec, 1973; Ost, 1987)also fared well in various clinical trials (Barlow, Rapee, & Brown, 1992; Borkovec & Costello,1993), and has often been part of CBT programs (e.g. Borkovec & Costello, 1993; Power et al.,

1990). According to DeRubeis and Crits-Cristoph (1998), only C(B)T has proved to be effectiveand specific, whereas AR has been proved to be effective. Only three studies directly comparedthese two approaches. One found no statistically significant differences, but had low statisticalpower (Barlow et al., 1992). The second found no significant differences immediately after treat-ment, but at 12-months follow-up CT seemed superior to AR (Borkovec & Costello, 1993). Thethird found the two approaches equally effective (Ost & Breitholtz, 2000).

In a recent overview of six controlled trials, Fisher and Durham (1999), using the STAI-traitas common measure, compared seven psychological treatments of GAD. Individual AR and indi-vidual C(B)T were found to be the most effective, and the most consistent in their positive effects,with about 63% recovered immediately after AR, and 48% after C(B)T. At a half year follow-up, 60% of the AR, and 51% of the C(B)T patients were recovered. Non-directive therapy, groupC(B)T and group BT were moderately effective (3138% recovery at half year follow-up), andindividual BT (11%) and analytical psychotherapy the least (4% recovery). Thus, the presentstudy is helpful as an independent test of whether the good results of AR and C(B)T achievedin other centers can be replicated, and as a much needed direct comparison of CT and AR.

A threat to external validity is the recruitment of subjects through media releases, and otherunnatural ways, as has been done in the typical GAD treatment study (e.g. recently by Ladouceuret al., 2000; Ost & Breitholtz, 2000). Two of the three previous studies directly comparing ARand CT for GAD used advertisements to recruit subjects (Borkovec & Costello, 1993; Ost &Breitholtz, 2000). By contrast, the GAD patients in the present study were not especially recruitedfor the study, but came from the regular population referred to a community mental health center.

A second threat to external validity is the use of stringent exclusion criteria. In the present studymost comorbid diagnoses were allowed, and many patients indeed had comorbid diagnoses. Athird threat to validity is the investigation of a treatment developed by the researchers. The findingthat researchers-alliance is related to stronger effects of the pertinent treatment, also called theallegiance-effect, is not uncommon (McNally, 1996). Independent replication is the best safe-guard against this bias (in general, independent replication is the most essential, but sometimesundervalued, verification tool in science). A relevant example are three studies each comparingClark and Salkovskis CT for panic disorder with Osts AR package in the treatment of panicdisorder. Clark and coworkers found CT to be superior to AR (Clark et al., 1994), whereas Ostsgroup found AR and CT equally effective (Ost & Westling, 1995). An independent replication


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635A. Arntz / Behaviour Research and Therapy 41 (2003) 633646

of our group demonstrated CT to be more effective than AR in the treatment of panic disorder(Arntz & van den Hout, 1996; see also McNally, 1996). Osts AR as treatment for GAD has onlybeen investigated by its developer and a coworker (Ost & Breitholtz, 2000). Thus, an independentreplication is needed to see whether their finding is equally effective as CT holds.

In sum, the present study aimed at comparing two psychological treatments for GAD, AR andCT, with respect to their immediate and long-term effects, in a sample of GAD patients representa-tive of the clinical population. The study is comparable to the study by Ost and Breitholtz, 2000,who compared the same treatment approaches. Although the comparison is not new, the presentstudy is valuable as an independent test, not biased by possible allegiance-effects, and becausethe investigation was done in a clinical sample of non-recruited patients with high rates of comor-bidity. Anxiety complaints, trait anxiety (notably heightened in these patients, cf. Fisher & Dur-ham, 1999), and a general psychopathology index (a composite score of a large number of self-report instruments) were the main outcome measures. Fisher and Durham (1999) have recently

published an analysis of recovery rates and clinically significant change in GAD across differentoutcome studies. Their norms enable the results of the present study to be compared with thoseof other studies.

2. Method

2.1. Patients

Patients of the Community Mental Health Center at Maastricht who were referred to the Aca-demic Section Behavior Therapy participated if they met the following criteria: (1) primary diag-nosis of GAD; (2) requesting treatment for their GAD; (3) older than 17 and younger than 70years; (4) no depressive disorder preceding the current episode of GAD or requiring immediatetreatment; (5) no behavior therapy received for their GAD; (6) no evidence of organic mentaldisorders accounting for the complaints, mental retardation, psychotic disorders, alcohol or drugdependence. All patients gave informed consent.

The first 14 patients of the present study were screened with a self-developed interview, whichscreened for presence of GAD symptoms as defined by the DSM-III-R. This interview alsoinstructed the screener to assess mood disorders, psychotic disorders, and possible organic factors(notably hyperthyroidism, caffeine consumption). In 1992, the Dutch version of the StructuredClinical Interview for DSM-III-R axis-I (SCID: Spitzer & Williams, 1986) became available, and

27 patients of the present study were screened with this instrument. The last four patients of thepresent sample were screened with the Dutch DSM-IV version of the SCID. Of the 47 patientswith a first diagnosis of GAD on axis-I in the inclusion period of 10.5 years, two did not enterthe trial because they received a primary diagnosis on axis-II, and they were accordingly treatedfor a personality disorder. The final sample consisted of 15 men and 30 women. Mean age was35.9 years (range 2060), 71.1% were married or living with a partner, 38% had a paid job (othersbeing ill, disabled, unemployed, housewife/househusband, student, etc.). Mean duration of GADwas 8.8 years (md = 5 years, range 135 years). Educational level was, in general, rather low:44.4% had lower level education, 40% medium level, and 15.6% some form of higher education.On Axis-I 22.2% had only a diagnosis of GAD, the others having secondary diagnoses (46.7%


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one, 13.3% two, 13.3% three, 2.2% four, and 2.2% five secondary diagnoses). The mean numberof diagnoses (2.33) did not differ significantly between conditions (MannWhitney U =220.5; Z = 0.717, p = 0.48). Anxiety diagnoses were most common as secondary diagnoses, 39were diagnosed (17 panic disorders, 13 social phobias, 4 specific phobias, 3 obsessive-compulsivedisorders, 2 PTSD). There were 16 mood disorders (11 major depressions, 5 dysthymic), 3 somato-form disorders, 3 eating disorders, 2 V-codes, 1 sexual disorder, and one adjustment disorder.

2.2. Treatments

Each treatment consisted of one pre-treatment session during which therapist and patient madeacquaintance, self monitoring of daily anxiety levels was introduced, and arrangements were madeabout sessions and measurements. Twelve weekly sessions of one hour each followed. After one

and six months, follow-up meetings were arranged.

2.2.1. Cognitive Therapy

CT was based on the approaches of Beck and Emery (1985) and Butler et al. (1991). Duringthe first session the cognitive model was introduced by formulating the patients problem in cogni-tive terms and sketching an idiosyncratic vicious circle involving catastrophic thoughts and anxi-ety. Challenging dysfunctional thoughts and formulating rational thoughts was introduced duringsession two. From the first session onwards patients monitored automatic thoughtspreceding/accompanying their anxiety. From the second session onwards, patients tried to chal-lenge their automatic thoughts and to formulate rational thoughts in their diaries. From the third

session onwards, behavioral experiments during and between the sessions were introduced to testcatastrophic beliefs. Underlying assumptions were identified and tested from session 6 onwards.Neither exposure in vivo nor relaxation training was part of CT. Behavioral experiments wereonly used to test specific beliefs, not to habituate to feared situations.

2.2.2. Applied relaxation

AR followed the protocol developed by Ost (1987). In session one an idiosyncratic viciouscircle stressing the role of bodily arousal in the maintenance of the problem was offered as anexplanation for the disorder. No reference was made to the possible role of automatic thoughtsand beliefs. Patients were told that it was possible to learn to reduce the autonomic arousal by

relaxation procedures, and that they would be helped to practice these procedures in graduallymore difficult situations. An overview of the 12-session program was given, showing patientshow they would learn to apply relaxation skills in still shorter times, and that they would learnto apply them in difficult situations. During treatment patients were taught to identify early signsof anxiety and to apply relaxation skills. Starting with progressive relaxation, the therapist taughtpatients to relax increasingly quickly, to apply relaxation skills during daily activities such aswalking, typing, driving a car, etc., and to use these skills to counter anxiety as early as possible.Patients were instructed to practice at least twice a day. During the last two weeks of treatmentgraduated exposure to feared situations was introduced so that patients could practice their ARskills in these situations.


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2.3. Therapists

Thirteen therapists conducted both treatments. There were weekly meetings, during which eachcase was presented in detail and adherence to the protocol was checked. Care was taken to excludecognitive techniques from the AR treatment, and exposure and relaxation techniques from the CTtreatment. AR was originally taught to our group in a workshop at our center by Lars-Goran Ost.Three of the 13 therapists participated in this workshop. The others were trained by the presentauthor. CT was introduced by Gillian Butler to the present author, who trained the other therapists.

2.4. Measures.

On a diary, subjects indicated their average level of anxiety during every 3 h (while not asleep)by filling in a figure between 0 and 100. These diaries were used in treatment to identify the

most anxious periods. (Originally, it was planned that the diaries should be used as a dependentmeasure, but unfortunately, there were too many missing). A Dutch version of Spielbergers StateTrait Anxiety Inventory was used as a measure of state and trait anxiety (alphas 0.91; vander Ploeg, Defares, & Spielberger, 1980). The SCL-90 was used as a multi-dimensional index ofpsychopathological complaints (alphas of subscales 0.72; alpha of anxiety scale = 0.88; alphatotal score 0.95; Arrindell & Ettema, 1981). The Fear of Fear questionnaire was used tomeasure fear ofanxiety symptoms and has good validity (van den Hout, van der Molen, Griez, &Lousberg, 1987). Of the Fear Questionnaire (Marks & Mathews, 1979) fear and avoidance scoresof the self-described main complaint, and of agoraphobic and social-phobic subscales were ana-lyzed. The Bouman Depression Inventory (Bouman, 1987) is a Dutch parallel test of the BeckDepression Inventory, with good psychometric properties (e.g. alphas = 0.92). There are threesubscales: mood, motivation and somatic complaints (mainly sleep problems).

2.5. Procedure and design.

At the end of the screening procedure the patient was informed about the study. Patients startedtreatment after a wait of 36 months. They were randomly allocated to condition and to the nextavailable therapist. Questionnaires were administered one week before treatment, after the 12thsession (posttest), 4 weeks after the posttest (follow-up 1) and 6 months after the posttest (follow-up 2). No additional treatment was given between posttest and first follow-up. For ethical reasons,patients could receive further treatment after follow-up 1, either for remaining GAD problems,

or for other problems.

2.6. Data reduction and analysis.

Before analyzing treatment effects, questionnaire subscale scores were subjected to PrincipalComponent Analysis followed by Varimax rotation in order to reduce the number of dependentvariables, and to increase statistical power. Scree plots were inspected. It appeared that both aone-factor and a four-factor solution were possible. With regards to the one-factor solution: alldependent variables loaded on the factor, which accounted for 41.8% of the variance. (A four-factor solution with factors reflecting anxiety, neuroticism/depression, interpersonal/phobic prob-


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lems, and sleep problems was also explored in the analyses, and produced strongly similar results.Therefore the results of the one-factor solution are reported here). A composite score was gener-ated by standardizing each subscale score across all assessment points by converting to Z-scores,and then averaging across the measures (see Arntz & van den Hout, 1996; Clark et al., 1994;Hollon et al., 1992; Rosenthal & Rosnow, 1991). Changes from pretest to later tests of compositescores were analyzed by ANCOVA using pretest levels as the covariate. Two measures were alsoseparately analyzed because they were judged to be especially relevant for GAD: the STAI-traitscale and the anxiety scale of the SCL-90. Both completers and intention-to-treat analyses werecarried out. Degrees of freedom can vary slightly due to occasional missing values.

3. Results

3.1. Pretest differences

Two significant differences were found: 4 of the 25 CT subjects had no partner, as comparedto 9 of the 20 AR subjects, Fishers Exact Test p = 0.032; and educational level was lower inthe AR condition than in the CT condition, t(43) = 2.57, p = 0.014. There were no differencesbetween the groups on other variables, including sex, age, work situation, duration of complaints,number of diagnoses, medication use, pretest panic frequency and pretest composite question-naire score.

3.2. Drop-outs

There were five dropouts from CT (20%), and three from AR (15%), NS. Two of the fivedropouts from CT and one of the three from AR claimed that they were recovered and that theydid not need further therapy. One CT patient stopped because of a pain problem requiring immedi-ate medical attention, and subsequently moved to another city, and one AR patient stoppedbecause of a severe depressive episode starting and worsening during treatment (the patient wasreferred to another unit). Two CT patients were dissatisfied with treatment and one AR patientstopped for unknown reasons and could not be contacted. Two of the (improved) dropouts, onein each condition, agreed to continue to participate in the assessments and they were included inthe completers analysis.

3.3. SCL-90 Anxiety

The anxiety subscale of the SCL-90 was separately analyzed as the most direct index of generalanxiety complaints. Fig. 1 depicts the mean scores at the four assessment points. A completersanalysis revealed highly significant decreases from pretest to posttest (main effect), t (37) =6.30, p 0.001, ES = 1.02; from pretest to first follow-up, t (37) = 5.90, p 0.001, ES =0.96; and from pretest to second follow-up, t (34) = 6.77, p 0.001, ES = 1.14. In the completerssample, ANCOVA using the pretest SCL-90 anxiety score as covariate revealed NS conditioneffects on posttest, F(1, 35) = 0.35, p = 0.56; on first follow-up, F(1, 35) = 3.52, p = 0.07 (infavor of AR); or on second follow-up, F(1, 32) = 0.06, p = 0.81. An intention to treat analysis


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Fig. 1. Mean scores for AR and CT at the four assessments for completers and intention to treat samples separately.

revealed NS condition effects at posttest, F(1, 42) = 0.74, p = 0.39, and at second follow-up,F(1, 42) = 0.02, p = 0.97. At first follow-up, however, AR was superior to CT, F(1, 42) =4.28, p = 0.045.

3.4. STAI-trait

The STAI-trait scale (see Table 1 for statistics and Fig. 1 for illustration) was separately ana-lyzed. A completers analysis revealed highly significant decreases from pretest to posttest (main

effect), t (37) = 3.29, p = 0.002, ES = 0.53; from pretest to first follow-up, t (38) = 3.52, p =0.001, ES = 0.56; and from pretest to second follow-up, t (34) = 3.71, p = 0.001, ES = 0.63. A

Table 1

Means (and standard deviations) of the STAI-trait scale (completers)

Condition Pretest Posttest Follow-up 1 Follow-up 2

CT 57.5 (8.3) 52.7 (10.3) 51.4 (10.1) 47.0 (12.8)

AR 53.7 (10.2) 47.6 (13.0) 44.1 (14.9) 44.8 (17.1)


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completers analysis by ANCOVA using pretest trait score as covariate revealed NS conditioneffects on posttest, F(1, 35) = 0.17, p = 0.68; on first follow-up, F(1, 36) = 1.68, p = 0.20; oron second follow-up, F(1, 32) = 0.04, p = 0.85. An intention to treat analysis (ANCOVA) revealedNS condition effects at posttest, F(1, 42) = 0.19, p = 0.67, at first follow-up, F(1, 42) =1.42, p = 0.24, or at second follow-up, F(1, 42)0.09, p = 0.77.

3.5. Composite score

First, a completers analysis was done. Paired t-tests revealed highly significant reductions inthe composite score at posttest, t(37) = 5.43, p 0.001, ES = 0.88; at first follow-up, t(37) =4.94, p 0.001, ES = 0.80; and at second follow-up t(34) = 6.25, p 0.001, ES = 1.06.ANCOVA using the pretest composite score as covariate revealed NS differences between con-ditions at posttest, F(1, 35) = 0.21, p = 0.65; at first follow-up, F(1, 35) = 1.36, p = 0.25; or at

second follow-up, F(1, 32) = 0.22, p = 0.64. Next, an intention-to-treat analysis was carried out,assuming similar improvement for the one improved CT drop-out who was not further assessedafter discontinuation, and no improvement for the unimproved drop-outs (see Fig. 1). Missingvalues were estimated by inter/extrapolation. ANCOVA using the pretest composite score ascovariate revealed NS differences between conditions at posttest, F(1, 42) = 0.40, p = 0.53; at

first follow-up, F(1, 42) = 1.63, p = 0.21; or at second follow-up, F(1, 42) = 0.004, p = 0.95.

3.6. Recovery rates and clinical significant change

Fisher and Durhams (1999) criteria for recovery (45) and clinical significant change (8)on the trait scale of the STAI were used to calculate proportions of patients meeting these criteriaat posttest and both follow ups. Table 2 shows the results. Although differences were NS, ARtended to be superior to CT, especially at first follow-up, when recovery rates are considered.Note, however, that patients in the CT condition had at pretest, on the average, higher scoresthan patients in the AR condition. Using Dutch norms of nonpsychiatric controls (m = 36.9, sd

= 8.48, cf. van der Ploeg et al., 1980), and the statistics of the present GAD sample (pretestSTAI-trait m = 55.78, sd = 9.29), the cut-off point c was 46.12, so that recovery could be definedslightly different (46). This influenced the results only for CT at second follow-up, Table 2,but the difference between conditions remained NS.

3.7. Results controlled for educational level and living together

Since conditions differed significantly as to educational level and living together, the ANCO-VAs were repeated with these two variables as additional covariates. Composite score and traitanxiety: there were no significant differences between conditions at posttest and both follow-upsafter controlling for these demographic variables (both completers and intention to treat analyses).SCL-90 Anxiety: there were no significant differences between conditions at posttest and secondfollow-up after controlling for these demographic variables (both completers and intention totreat analyses). As in the previous analyses, at first follow-up AR tended to be superior to CT,completers F(1, 33) = 3.14, p = 0.086, intention to treat F(1, 40) = 4.50, p = 0.04. Living togetherwas positively related to outcome at first follow-up (completers F (1, 33) = 3.64, p = 0.065;


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Table2

Proportionsofpatientsmeeting

criteriaforreliablychangeandrecoveryatthetraitscaleoftheSTA

I

Condition

Posttest

Follo

w-up1

F

ollow-up2

Reliablychanged

Recovered

Relia

blychanged

Recovered

R

eliablychanged

Recovered

CT

40.0

%

35.0

%

47.6

%

28.6

%

50.0

%

50.0

%a

/55.0%

b

AR

33.3

%

44.4

%

50.0

%

50.0

%

46.7

%

53.3

%

Note:Noneofthedifferencesbetweenconditionswassignificant.

ResultsareidenticalfortheFisher

andDurham

(1999)normsandDutchnorms,

exceptforCTatFU2.

a

FisherandDurhamsnorm

s.

b

Dutchnorms.


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intention to treat F(1, 40) = 3.48, p =0.07), and at second follow-up (completers F(1, 30) =4.51, p = 0.04; intention to treat F(1, 40) = 5.36, p = 0.026).

3.8. Results at half-year follow-up controlled for additional treatment

Fifty-six percent of the patients received some form of additional treatment between the one-month and 6 months follow-up, the number of sessions ranging from 1 to 20 (m = 3.7). Differencesbetween conditions were NS as to number of patients receiving additional treatment, and to num-ber of additional sessions. Second follow-up data were re-analyzed with number of additionalsessions as an additional covariate, but differences between conditions remained NS. This suggeststhat CTs catching up with AR at second follow-up, compared to first follow-up, was not relatedto the amount of additional treatment received in the period between the two follow-ups

3.9. SCID diagnosed cases

The establishment of diagnoses (including exclusion criteria) might have been more reliableand valid using the SCID. Cases not diagnosed with the SCID (n = 14) were therefore excludedand the data were re-analyzed (for sample size reasons intention-to-treat only). Results were simi-lar to those obtained with the complete sample: strong treatment effects, and no differencesbetween conditions at posttest or at second follow-up. At first follow-up, AR tended to do betterthan CT, but the differences were far from significant. Since the pattern was similar to that ofthe full sample, the loss of significance in case of the SCL-90 anxiety scale is probably causedby reduction of power.

4. Discussion

As has been mentioned by others, there is a disturbing trend to understudy GAD (Dugas, 2000).The present study is only the fourth that offers a direct comparison between two of the mosteffective treatments for GAD, AR and CT. By and large, both approaches seemed equally effec-tive. As recovery rates and rates of clinically significantly change are comparable to those foundin other studies (Fisher & Durham, 1999; Ost & Breitholtz, 2000), the lack of difference betweenAR and CT does not seem to be caused by a general ineffectiveness of our treatments.

Recovery rates at second follow-up were highly comparable to those found by Fisher and

Durham, who collapsed results of 6 randomized trials. Fisher and Durham found a recovery rateat 6 months follow-up of 60% for AR (the present study 53.3%), and 51% for C(B)T (the presentstudy 50 or 55%, depending on whether Dutch or international norms were used). At posttestrecovery rates were lower than those calculated by Fisher and Durham, especially for CT, suggest-ing a slower change process in the present study. The percentages are also highly similar to thosefound by Ost and Breitholtz (2000), which is a reassuring finding in that it demonstrates that Ostand Breitholtz findings are not related to allegiance effects or to sampling biases.

Though not convincingly significant in a statistical sense, the present results suggest that AR,more than CT, had a further anxiety reducing effect one month after treatment, whereas CT caughtup with AR at six months follow-up. It is unlikely that additional treatment during FU caused


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CT to catch up with AR, since (i) the proportion of patients receiving additional treatment wasequal in both conditions, (ii) the number of additional sessions was equal, and (iii) covarying outthe effects of additional sessions did not change the conclusions at the half-year follow-up. Withhindsight, it would have been interesting to study the patients condition at longer follow-upperiods, to see whether CT would become superior to AR. Note that Borkovec and Costello(1993) found CT to be superior to AR at a one year follow-up, but not at posttest. Similarly, indirect comparisons C(B)T was superior to BT in the long run (Butler et al., 1991; Durham &Turvey, 1987; Durham et al., 1994). On the other hand, Ost and Breitholtz (2000) did not observesuch an effect at their 1 year follow-up.

There is good reason to believe that the present results are consistent with other findings.However, before accepting their validity the following points should be considered. (1) The first14 patients were diagnosed using a checklist rather than a SCID interview. This raises the possi-bility (in our view unlikely) of false diagnosis, or of the improper assessment of exclusion diag-

noses. Reanalysis of the 34 cases who were diagnosed with the SCID showed that the resultswere stable. (2) The dependent variables lacked an instrument specifically tailored to assess GADintensity (as is the case for most other studies). The development of an instrument that couldserve as an international standard would be most welcome. We tried to solve this problem byusing three dependent variables: the SCL-90 anxiety subscale as the most direct measure ofintensity/frequency of anxiety symptoms, the STAI-trait scale as a measure of the general tendencyto be overanxious and to worry too much, and a composite measure as an indication of generalpsychopathology. (3) There was no formal treatment integrity check, for instance by having inde-pendent raters rate audiotapes of the sessions, although checks were consistently done by havingtherapists report every week about treatment in supervision sessions. (4) The study suffered fromdropout. Fortunately, two patients agreed to continue assessments, and an intention-to-treat analy-sis showed no major differences compared with analysis of completers only. (5) Additional treat-ment was offered when needed, sometimes for GAD, sometimes for other problems (note thecomorbidity in the sample), and this may have influenced the half-year follow-up assessment.However, as was reasoned earlier, this was not likely to have influenced the difference betweenCT and AR at that time. Additional treatment appeared to correlate with higher scores at half-year follow-up, indicating that it was requested by those patients with more severe, or morecomplex problems.

The particularly strong points of this study are the independence of our center as to treatmentpreference, the relatively high number of subjects and the high external validity. The GAD patientswere not especially recruited for the study, but came from the regular population referred to the

institute; many patients had comorbid diagnoses; and patients educational level was relativelylow. The fact that 45 of the 47 patients in our center with GAD as first axis-1 diagnosis partici-pated, the other two having primarily axis-2 problems, underlines the high external validity ofthe present study.

Though both AR and CT appear to be good treatments for GAD, there is room for improvement.Effect sizes appeared to be moderate to high (in the 0.961.14 range for SCL-90 anxiety score,in the 0.801.10 range for the composite score, in the 0.530.63 range for trait anxiety), andrecovery rates seem fairly high, but comparison with the recent successes of CBT for panicdisorder, suggest that further increases could be achieved (similar comments were made by Ost &Breitholtz, 2000). At least three possibilities have been suggested. Borkovec and Newman (1999)


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have drawn attention to interpersonal issues that may be important in GAD, suggesting that manyGAD patients suffer from an overly nurturant attitude to others, at the cost of healthy self-servingattitudes and behaviors. A treatment specifically addressing these issues might be helpful. Othershave suggested that meta-cognitions and attentional processes play an important role in main-taining the disorder, especially in fueling worry (Wells, 1995). Specific forms of CT addressingthese issues have been proposed. Only one study has tested a more specific CBT treatment andfound it to be highly effective, but this study compared the active treatment only to a wait listcontrol group and used a artificially recruited sample (Ladouceur et al., 2000). A third possibilityis that our treatments of GAD are generally not long enough. It is noteworthy that the one studythat found disappointing effects of CT used only 8 sessions of CT (Blowers, Cobb, & Mathews,1987). Similarly, Durham et al., 1994 Fischer and Durham, 1999) found that a more intensiveform of CT (1620 sessions) was clearly superior to a less intensive form (with only 810sessions), especially in the long run.

A fourth possibility may be added: that treatments so far were not maximally effective inchanging the trait-like aspects of GAD. It is widely recognized that GAD has strong trait-likecharacteristics and, indeed, most patients report an early (and not exact) start of the problem anda chronic course (Rapee, 1991). The interpersonal and cognitive trait-like characteristics of GADmight be explained by an integrative model, hypothesizing that early maladaptive schemas, trig-gered by current uncertainty, maintain the disorder. Early childhood experiences relating to uncer-tainty about and threat to the availability and stability of caretakers may have led to a nurturantattitude to the caretaker (instead of the other way around), a constant sense of threat, and thefeeling that the threat cannot be coped with. These childhood experiences may have led to thedevelopment of schemas that make the person vulnerable to develop GAD once faced with currentuncertainty. GAD patients might profit from CT approaches that specifically address schemaissues, like those that have been developed for personality disorders, and approaches addressingearly learning experiences might be especially helpful (e.g. Arntz & Weertman, 1999).

In summary, the present study confirms earlier reports that both AR and CT are effectivetreatments for GAD. There was some indication that AR showed a higher effectiveness in furtherreducing GAD problems one month after treatment, but at six-months follow-up CT appeared tobe related to further reduction of problems, catching up with AR. Results remained stable whenfactors potentially influencing the effects were investigated: drop-outs (intention-to-treat analyses);educational level; marital status; nonSCID-diagnosed cases; and additional treatment during thesecond follow-up period. Thus, the conclusions seem relatively reliable. Effects of treatment werestronger on symptom level than on trait level. The results suggest that there is room for improve-

ment. New studies should focus on factors like duration of treatment, changing trait-like factors(like core schemas), worry, meta cognition, attentional processes, and interpersonal issues.

Acknowledgements

Gillian Butler and Lars-Goran Ost are acknowledged for their help in preparing the study. Thecenters research assistants are acknowledged for their help in acquiring, scoring and entering thedata. The therapists are thanked for treating the patients of this study. Gillian Butler gave valuablecomments on a previous version of this report.


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