Expanding our conceptualization of and treatment for generalized anxiety disorder: Integrating mindfulness/acceptance-based approaches with existing cognitive-behavioral models

Clinical Psychology: Science and Practice

Volumn 9, Issue 1, 2002, Pages 54-68

  Roemer, Lizabeth ^a   Orsillo, Susan M ^b  

^a UNIVERSITY OF MASSACHUSETTS BOSTON   (United States)

^b BOSTON UNIVERSITY SCHOOL OF MEDICINE   (United States)

Author keywords

Acceptance based therapy; Experiential avoidance; Generalized anxiety disorder; Mindfulness; Worry

Indexed keywords

BEHAVIOR; BEHAVIOR THERAPY; BIOLOGICAL MODEL; COGNITION; DEPRESSION; FOLLOW UP; GENERALIZED ANXIETY DISORDER; LEISURE; MUSCLE RELAXATION; PSYCHOTHERAPY; RESEARCH; REVIEW;

EID: 0037814807     PISSN: 09695893     EISSN: None     Source Type: Journal    
DOI: 10.1093/clipsy/9.1.54     Document Type: Review

References (103)

1. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.
2. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author.
3. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
4. Barlow, D. H. (1988). Anxiety and its disorders: The nature and treatment of anxiety and panic. New York: Guilford.
5. Barlow, D. H. (in press). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). New York: Guilford.
6. Barlow, D. H., Rapee, R. M., & Brown, T. A. (1992). Behavioral treatment of generalized anxiety disorder. Behavior Therapy, 23, 551-570.
7. Beck, A .T., & Emery, G. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books.
8. Bernstein, D. A., Borkovec, T. D., & Hazlett-Stevens, H. (2000). New directions in progressive relaxation training: A guidebook for helping professionals. Westport, CT: Praeger Publishers.
9. Borkovec, T. D. (1994) The nature, functions, and origins of worry. In G. C. L. Davey & F. Tallis (Eds.), Worrying: Perspectives on theory, assessment, and treatment (pp. 5-34). New York: Wiley.
10. Borkovec, T. D. (1999, June). The nature and psychosocial treatment of generalized anxiety disorder. Paper presented at the annual meeting of the American Psychological Society, Denver, CO.
11. Borkovec, T. D., Abel, J. E., & Newman, H. (1995). Effects of psychotherapy on comorbid conditions in generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 63, 479-483.
12. Borkovec, T D., Alcaine, O., & Behar, E. (in press). Avoidance theory of worry and generalized anxiety disorder. In R. G. Heimberg, C. E. Turk, & D. S. Mennin (Eds.), Generalized anxiety disorder: Advances in research and practice. New York: Guilford.
13. Borkovec, T. D., & Costello, E. (1993). Efficacy of applied relaxation and cognitive-behavioral therapy in the treatment of generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 61, 611-619.
14. Borkovec, T. D., Hazlett-Stevens, H., & Diaz, M. E. (1999). The role of positive beliefs about worry in generalized anxiety disorder and its treatment. Clinical Psychology and Psychotherapy, 6, 126-138.
15. Borkovec, T. D., & Hu, S. (1990). The effect of worry on cardiovascular response to phobic imagery. Behaviour Research and Therapy, 28, 69-73.
16. Borkovec, T. D., & Inz, J. (1990). The nature of worry in generalized anxiety disorder: A predominance of thought activity. Behaviour Research and Therapy, 28, 153-158.
17. Borkovec, T D., & Roemer, L. (1994). Generalized anxiety disorder. In R. T. Ammerman & M. Hersen (Eds.), Handbook of prescriptive treatments for adults (pp. 261-281). New York: Plenum.
18. Borkovec, T. D., & Roemer, L. (1995). Perceived functions of worry among generalized anxiety disorder subjects: Distraction from more emotionally distressing topics? Journal of Behavior Therapy and Experimental Psychiatry, 26, 25-30.
19. Borkovec, T. D., & Ruscio, A. M. (2001). Psychotherapy for generalized anxiety disorder. Journal of Clinical Psychiatry, 62, 37-42.
20. Borkovec, T. D., Shadick, R., & Hopkins, M. (1991). The nature of normal and pathological worry. In R. Rapee & D. H. Barlow (Eds.), Chronic anxiety: Generalized anxiety disorder and mixed anxiety-depression (pp. 29-51). New York: Guilford.
21. Brown, T. A. (1999). Generalized anxiety disorder and obsessive-compulsive disorder. In T. Millon, P. H. Blaney & R. D. Davis (Eds.), Oxford textbook of psychopathology (pp. 114-143). New York: Oxford University Press.
22. Brown, T. A., & Barlow, D. H. (1992). Comorbidity among anxiety disorders: Implications for treatment and DSM-IV. Journal of Consulting and Clinical Psychology, 60, 835-844.
23. Brown, T. A., Barlow, D. H., & Liebowitz, M. R. (1994). The empirical basis of generalized anxiety disorder. American Journal of Psychiatry, 151, 1272-1280.
24. Butler, G. (1994). Treatment of worry in generalized anxiety disorder. In G. C. L. Davey & F. Tallis (Eds.), Worrying: Perspectives on theory, assessment and treatment (pp. 35-59). New York: Wiley.
25. Butler, G., Fennell, M., Robson, P., & Gelder, M. (1991). Comparison of behavior therapy and cognitive behavior therapy in the treatment of generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 59, 167-175.
26. Butler, G., Gelder, M., Hibbert, G., Cullington, A., & Klimes, I. (1987). Anxiety management: Developing effective strategies. Behaviour Research and Therapy, 25, 517-522.
27. Butler, G., & Matthews, A. (1987). Anticipatory anxiety and risk perception. Cognitive Therapy and Research, 11, 551-565.
28. Carrington, P. (1993). Modern forms of meditation. In P. M. Lehrer & R. L. Woolfolk (Eds.), Principles and practice of stress management (pp. 139-168). New York: Guilford.
29. Cartwright-Hatton, S., & Wells, A. (1997). Beliefs about worry and intrusions: The Meta-Cognitions Questionnaire and its correlates. Journal of Anxiety Disorders, 11, 279-296.
30. Connor, K. M., & Davidson, J. R. T. (1998). Generalized anxiety disorder: Neurobiological and pharmacotherapeutic perspectives. Biological Psychiatry, 44, 1286-1294.
31. Cordova, J. V. & Jacobson, N. S. (1993). Couple distress. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (2nd ed., pp. 481-512). New York: Plenum.
32. Craske, M. G. (1999). Anxiety disorders: Psychological approaches to theory and treatment. Boulder, CO: Westview Press.
33. Craske, M. G., & Barlow, D. H. (1993). Panic disorder and agoraphobia. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (2nd ed., pp. 1-47). New York: Plenum.
34. Craske, M. G., Barlow, D. H., & O'Leary, T. (1992). Mastery of your anxiety and worry. Albany, NY: Graywind.
35. Davey, G. C. L., Tallis, F., & Capuzzo, N. (1996). Beliefs about the consequences of worrying. Cognitive Therapy and Research, 20, 499-520.
36. Dugas, M. J., Freeston, M. H., Ladouceur, R., Rheaume, J., Provencher, M., & Boisvert, M. M. (1998). Worry themes in primary GAD, secondary GAD and other anxiety disorders, Journal of Anxiety Disorders, 12, 253-261.
37. Dugas, M. J., Gagnon, F., Ladouceur, R., & Freeston, M. (1998). Generalized anxiety disorder: A preliminary test of a conceptual model. Behaviour Research and Therapy, 36, 215-226.
38. Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20-35.
39. Follette, V. M. (1994). Survivors of child sexual abuse: Treatment using a contextual analysis. In S. C. Hayes, N. S. Jacobson, V. M. Follette, & M. J. Dougher (Eds.), Acceptance and change: Content and context in psychotherapy (pp. 255-268). Reno, NV: Context Press.
40. Freeston, M. H., Dugas, M. J., & Ladouceur, R. (1996). Thoughts, images, worry, and anxiety. Cognitive Therapy and Research, 20, 265-273.
41. Freeston, M. H., Rhéaume, J., Letarte, H., Dugas, M. J., & Ladouceur, R. (1994). Why do people worry? Personality and Individual Differences, 17, 791-802.
42. Goldfried, M. R. (1971). Systematic desensitization as training in self-control. Journal of Consulting and Clinical Psychology, 37, 228-234.
43. Greenberg, L. S., & Safran, J. D. (1987). Emotions in psychotherapy. New York: Guilford.
44. Greenberg, P. E., Sisitsky T., Kessler, R. C., Pinkelstein, S. N., Berndt, E. R., Davidson, J. R. T., Ballenger, J. C., & Fyer, A. J. (1999). The economic burden of the anxiety disorders in the 1990s. Journal of Clinical Psychiatry, 60, 427-435.
45. Hanh, T. N. (1976). The miracle of mindfulness: A manual for meditation. Boston: Beacon Press.
46. Hayes, S. C. (1999, November). Buddhist philosophy and CBT. A panel discussion at the Annual Meeting of the Association for Advancement of Behavior Therapy, Toronto, Canada.
47. Hayes, S. C., Bissett, R. T., Korn, Z., Zettle, R. D., Rosenfarb, I. S., Cooper, L. D., & Grundt, A. M. (1999). The impact of acceptance versus control rationales on pain tolerance. Psychological Record, 49, 33-47.
48. Hayes, S. C., Bissett, R. T., Strosahl, K., Follette, W. C., Polusney, M. A., Pistorello, J., Toarmino, D., Batten, S. V., Dykstra, T. A., Stewart, S. H., Zvolensky, M. J., Eifert, G. H., Bond, F. W., & Bergan, J. (2001). Psychometric properties of the Acceptance and Action Questionnaire (ACT). Manuscript in preparation.
49. Hayes, S. C., Jacobson, N. S., Follette, V. M., & Dougher, M. J. (Eds.). (1994). Acceptance and change: Content and context in psychotherapy. Reno, NV: Context Press.
50. Hayes, S. C., & Ju, W. (1998). Rule-governed behavior. In W. O'Donahue (Ed.), Learning and behavior therapy (pp. 374-391.) Boston: Allyn and Bacon.
51. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford.
52. Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M. & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152-1168.
53. Heffner, M., Eifert, G. H., Spira, A. P., Tennis, K. K., Burnworth, J., & Tenney E. (2000, November). The effects of acceptance and control contexts on avoidance of an aversive event. Poster presented at the annual meeting of the Association for Advancement of Behavior Therapy, New Orleans, LA.
54. Hoehn-Saric, R., & McLeod, D. R. (1988). The peripheral sympathetic nervous system: Its role in normal and pathological anxiety. Psychiatric Clinics of North America, 11, 375-386.
55. Kabat-Zinn, J. (1994). Wherever you go there you are. New York: Hyperion.
56. Kabat-Zinn, J., Massion, A. O., Kristeller, J., Peterson, L. G., Fletcher, K. E., Pbert, L., Lenderking, W. R., & Santorelli, S. F. (1992). Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. American Journal of Psychiatry, 149, 936-943.
57. Ladouceur, R., Dugas, M. J., Freeston, M. H., Léger, E., Gagnon, F., & Thibodeau, N. (2000). Efficacy of a new cognitive-behavioral treatment for generalized anxiety disorder: Evaluation in a controlled clinical trial. Journal of Consulting and Clinical Psychology, 68, 957-964.
58. Lang, P. J. (1985). The cognitive psychophysiology of emotion: Fear and anxiety. In A. H. Tuma & J. D. Maser (Eds.), Anxiety and the anxiety disorders (pp. 131-170). Hillsdale, NJ: Erlbaum.
59. Lehrer, P. M., & Woolfolk, R. L. (1993). Specific effects of stress management techniques. In P. M. Lehrer & R. L. Woolfolk (Eds.), Principles and practice of stress management (pp. 481-520). New York: Guilford.
60. Linehan, M. M. (1993a). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford.
61. Linehan, M. M. (1993b). Skills training manual for cognitive behavioral treatment of borderline personality disorder. New York: Guilford.
62. Linehan, M. M. (1994). Acceptance and change: The central dialectic in psychotherapy. In S. C. Hayes, N. S. Jacobson, V. M. Follette, and M. J. Dougher (Eds.), Acceptance and change: Content and context in psychotherapy (pp. 73-86). Reno, NV: Context Press.
63. Linehan, M. M., Kanter, J. W., & Comtois, K. A. (1999). Dialectical behavior therapy for borderline personality disorder: Efficacy, specificity, and cost effectiveness. In D. S. Janowsky (Ed.), Psychotherapy indications and outcomes (pp. 93-118). Washington, DC: American Psychiatric Press.
64. Linehan, M. M., Tutek, D. A., Heard, H. L., & Armstrong, H. E. (1994). Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. American Journal of Psychiatry, 151, 1771-1776.
65. Lyonfields, J. D., Borkovec, T. D., & Thayer, J. F. (1995). Vagal tone in generalized anxiety disorder and the effects of aversive imagery and worrisome thinking. Behavior Therapy, 26, 457-466.
66. MacLeod, A. K., Williams, J. M. G., & Bekerian, D. A. (1991). Worry is reasonable: The role of explanations in pessimism about future personal events. Journal of Abnormal Psychology, 100, 478-486.
67. Marlatt, G. A. (1994). Addiction, mindfulness and acceptance. In S. C. Hayes, N. S. Jacobson, V. M. Follette, & M. J. Dougher (Eds.), Acceptance and change: Content and context in psychotherapy (pp. 175-197). Reno, NV: Context Press.
68. Marten, P. A., Brown, T. A., Barlow, D. H., Borkovec, T. D., Shear, K. M., & Lydiard, R. B. (1993). Evaluation of the ratings comprising the associated symptom criterion of DSM-III-R generalized anxiety disorder. Journal of Nervous and Mental Disease, 181, 676-682.
69. Martin, J. R. (1997). Mindfulness: A proposed common factor. Journal of Psychotherapy Integration, 7, 291-312.
70. Matthews, A. (1990). Why worry? The cognitive function of anxiety. Behaviour Research and Therapy, 28, 455-468.
71. Metzger, R. L., Miller, M. L., Cohen, M., Sofka, M., & Borkovec, T. D. (1990). Worry changes decision-making: The effect of negative thoughts on cognitive processing. Journal of Clinical Psychology, 46, 78-88.
72. Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 28, 487-495.
73. Miller, J. J., Fletcher, K. & Kabat-Zinn, J. (1995). Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. General Hospital Psychiatry, 17, 192-200.
74. Molina, S., Borkovec, T. D., Peasley C., & Person, D. (1998). Content analysis of worrisome streams of consciousness in anxious and dysphoric participants. Cognitive Therapy and Research, 22, 109-123.
75. Mowrer, O. H. (1960). Learning theory and behavior. New York: Wiley.
76. Nemeroff C. J., & Karoly, P. (1990). Operant methods. In F. H. Kanfer & A. P. Goldstein (Eds.), Helping People Change (4th ed., pp. 122-160). Boston: Allyn & Bacon.
77. Newman, M. G. (2000). Recommendations for a cost-offset model of psychotherapy allocation using generalized anxiety disorder as an example. Journal of Consulting and Clinical Psychology, 68, 549-555.
78. Newman, M. G., Zuellig, A. R., Kachin, K. E., & Constantino, M. J. (2001). The reliability and validity of the GAD-Q-IV: A revised self-report measure. Manuscript submitted for publication.
79. Orsillo, S. M., Roemer, E., & Barlow, D. H. (2001). Integrating acceptance and mindfulness into existing cognitive behavioral treatment for GAD: A case study. Manuscript submitted for publication.
80. Öst, L. (1987). Applied relaxation: Description of a coping technique and review of controlled studies. Behaviour Research and Therapy, 25, 397-409.
81. Purdon, C. (1999). Thought suppression and psychopathology. Behaviour Research and Therapy, 37, 1029-1054.
82. Roemer, L., & Borkovec, T. D. (1993). Worry: Unwanted cognitive experience that controls unwanted somatic experience. In D. M. Wegner & J. Pennebaker (Eds.), Handbook of mental control (pp. 220-238). Englewood Cliffs, NJ: Prentice-Hall.
83. Roemer, E., & Borkovec, T. D. (1994). Effects of suppressing thoughts about emotional material. Journal of Abnormal Psychology, 103, 467-474.
84. Roemer, L., Molina, S., & Borkovec, T. D. (1997). An investigation of worry content among generally anxious individuals. Journal of Nervous and Mental Disease, 185, 314-319.
85. Roemer, L., & Orsillo, S. M. (2001, July). The role of experiential avoidance in generalized anxiety disorder. Paper presented at the annual convention of the World Congress of Behavioral and Cognitive Therapy.
86. Roemer, L., Orsillo, S. M., & Barlow, D. H. (in press). In D. H. Barlow, Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). New York: Guilford.
87. Rogers, C. R. (1961). On becoming a person: A therapist's view of psychotherapy. Boston: Houghton Mifflin.
88. Souetre, E., Lozet, H., Cimarosti, I., Martin, P., Chignon, J. M., Ades, J., Tignol, J., & Darcourt, G. D. (1994). Cost of anxiety disorders: Impact of comorbidity. Journal of Psychosomatic Research, 38, 151-160.
89. Stöber, J. (1998). Worry, problem elaboration and suppression of imagery: The role of concreteness. Behaviour Research and Therapy, 36, 751-756.
90. Strosahl, K. D., Hayes, S. C., Bergan, J., & Romano, P. (1998). Assessing the field effectiveness of Acceptance and Commitment Therapy: An example of the manipulated training research method. Behavior Therapy, 29, 35-64.
91. Teasdale, J. D., Segal, Z., & Williams, J. M. (1995). How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? Behavior Research and Therapy, 33, 25-39.
92. Thayer, J. F., Friedman, B. H., Borkovec, T. D., Johnsen, B. H., & Molina, S. (2000). Phasic heart period reactions to cued threat and non-threat stimuli in generalized anxiety disorder. Psychophysiology, 37, 361-368
93. Vrana, S. R., Cuthbert, B. N., & Lang, P. J. (1986). Fear imagery and text processing. Psychophysiology, 23, 247-253.
94. Wegner, D. M. (1994). Ironic processes of mental control. Psychological Review, 101, 34-52.
95. Wells, A. (1995). Meta-cognition and worry: A cognitive model of generalized anxiety disorder. Behavioural and Cognitive Psychotherapy, 23, 301-320.
96. Wells, A. (1999). A metacognitive model and therapy for generalized anxiety disorder. Clinical Psychology and Psychotherapy, 6, 86-95.
97. Wells, A., & Carter, K. (1999). Preliminary tests of a cognitive model of generalized anxiety disorder. Behaviour Research and Therapy, 37, 585-594.
98. Wells, A., & Papageorgio, C. (1995). Worry and the incubation of intrusive images following stress. Behaviour Research and Therapy, 33, 579-583.
99. Williams, J. M. G., Teasdale, J. D., Segal, Z. V., & Soulsby, J. (2000). Mindfulness-based cognitive therapy reduces over-general autobiographical memory in formerly depressed patients. Journal of Abnormal Psychology, 109, 150-155.
100. Wittchen, H-U, Zhao, S., Kessler, R. C., & Eaton, W. W. (1994) DSM-III-R generalized anxiety disorder in the National Comorbidity Survey. Archives of General Psychiatry, 51, 355-364.
101. Woodman, C. L., Noyes, R., Black, D. W., Schlosser, S., & Yagia, S. J. (1999). A five year follow-up study of generalized anxiety disorder and panic disorder. Journal of Nervous and Mental Disease, 187, 3-9.
102. Yonkers, K. A., Warshaw, M. G., Massion, A. O., & Keller, M. B. (1996). Phenomenology and course of generalized anxiety disorder. British Journal of Psychiatry, 168, 308-313.
103. Zettle, R. D., & Rains, J. C. (1989). Group cognitive and contextual therapies in treatment of depression. Journal of Clinical Psychology, 45, 436-445.