Nancy A. Melville

April 10, 2017

SAN FRANCISCO – The use of a brief intervention that focuses on one component of cognitive-behavioral therapy (CBT) — monitoring of worry ― shows efficacy as an easy-to-use clinical tool to facilitate the broader treatment of generalized anxiety disorder, new research shows.

Dubbed the Worry Outcome Journal, the tool was designed to place greater focus on one key component of CBT, reported study investigator Lucas LaFreniere, PhD, of the Pennsylvania State University, in State College.

"CBT is well known as being efficacious for a great variety of disorders, but when we test CBT, it is typically as a full-treatment package, while many of the individual components may have not been evaluated independently," he said.

"If we are to say our treatments are empirically supported in a completely thorough way, we should be establishing empirical support for these individual components, as well as full treatment packages."

The findings were presented here at the Anxiety and Depression Association of America (ADAA) Conference 2017.

Worry Significantly Reduced

In the CBT model, the monitoring of worrying thoughts is a commonly used, albeit untested, component in which the patient takes note of specific worrisome predictions about the future that can be driving anxiety and then objectively observes the real-life outcomes of those worries.

With the Worry Outcome Journal, worrying is dissected in a similar fashion. The worrying is documented in the journal at scheduled times, with consideration given to the costs of such worries, as well as the estimated probabilities and outcomes of those worries.

To evaluate the journal's efficacy, the authors recruited 51 participants with generalized anxiety disorder. The patients were randomly assigned either to the use of a worry outcome journal or the use of a thought log (control condition) for 10 days.

Those using the Worry Outcome Journal were instructed to document their worries in the journal and to make concrete, specific predictions of the future in relation to the worries; to rate the worries in terms of level of distress and cognitive interference; and to track outcomes, including whether outcomes turned out better than, as bad as, or worse than expected.

Those in the control group, who used the thought log, were instructed only to complete a record of everyday thoughts (not worries or their probabilities) and to rate the amount of distress and interference associated with the thoughts.

All participants were randomly prompted by text message four times each day to record their entries on paper. They were also instructed to enter their log or journal entries each night.

In the post-intervention assessment, most of the described worries – 91% ― were not realized.

Patients who used the Worry Outcome Journal showed significantly greater reductions in levels of worry post-intervention compared to the control group, as assessed using the Penn State Worry Questionnaire (P = .04).

At a 30-day follow-up, a marginally significant difference was seen with a moderate effect size (P = .07), and the treatment gains were maintained.

Tough to Treat

Secondary outcomes were changes in general anxiety disorder, as assessed with the General Anxiety Disorder Questionnaire for DSM-IV. No differences were seen between the Worry Outcome Journal group and the control group, there were no significant differences in terms of change for worry-related beliefs, including positive, negative, and uncontrollability beliefs.

The findings are nevertheless important in light of the common struggles to treat generalized anxiety disorder, Dr LaFreniere said.

"Generalized anxiety disorder is very tough to treat – it's resilient to a lot of therapies, and in some studies, we see improvement in as few as 50% to just a third of patients, so there is work that needs to be done.

"The findings indicate that the Worry Outcome Journal may be a viable, ecological, momentary intervention for reducing worry in generalized anxiety disorder, and longer practice with the journal may yield stronger results," he said.

"A normal CBT protocol may involve 8 to 20 weeks undergoing treatment, and here we've only looked at 10 days, so it would be really interesting to see what this would look like if used for a longer period of time.

"But it may not be sufficient for comprehensive generalized anxiety disorder treatment, however," Dr LaFreniere added. "The journal may be best used as a component within a complete CBT program."

Commenting on the study, Richard Zinbarg, PhD, underscored the steep challenges in the treatment of generalized anxiety disorder.

"The fact is, this isn't like an infection, where you can take some penicillin and have a cure rate above 90%. Generalized anxiety disorder is much more difficult to treat.

"So we clearly have lots of room for improvement, and very little work has been done on our traditional CBT packages, so I loved this paper," he said.

Dr LaFreniere and Dr Zinbarg have disclosed no relevant financial relationships.

Anxiety and Depression Association of America (ADAA) Conference 2017. Presented April 8, 2017.


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