by Joye C. Anestis
Generalized anxiety disorder (GAD) is a pernicious and highly uncomfortable mental illness. According to the DSM-IV-TR (APA, 2000), the symptoms include:
- excessive anxiety and worry that is present in the majority of days over at least 6 months,
- worry over a variety of domains (e.g., work, school, safety of loved ones),
- difficulty in stopping and controlling the worry,
- the presence of at least 3 of 6 physical anxiety symptoms (only one of these is needed if the client is a child): feeling restless or on edge, tiring easily, concentration problems, irritability, muscle tension, sleep disturbance
This illness can be diagnosed in childhood, adulthood, and late-life. In fact, most of the individuals who meet criteria for GAD note that they have been "worriers" all of their life. Many of their thoughts are characterized by "what ifs": "what if my husband dies?", "what if I fail this test?", "what if I lose my job?". Sometimes these "what ifs" are realistic, but many times the "what if" is highly unlikely and/or the potential outcome of the "what if" is not as catastrophic as the client feels. For example, a client with GAD who worries "what if I fail this test?" often believes that failing one test will lead to failing the class, which will lead to flunking out of school, which will cause them to never be able to get a job. All of this is possible, but unlikely. What are the odds that failing one test will have catastrophic life consequences? It is interesting to note that the worries present in a person with GAD are not qualitatively different than those in a non-GAD person (we've all had experience with worry thoughts), but GAD worries are excessive and (seemingly) uncontrollable. As can be deduced from the criteria, chronic worry is accompanied by physiological overarousal (e.g., feelings of tension and of being "keyed up") as well as behavioral avoidance. GAD is heritable (Kendler et al., 1992), and more common in women than in men (APA, 2000). Prevalence rates vary but estimates in community samples are generally around 5% (APA, 2000). These prevalence rates tend to be higher in the elderly (a point I'll return to later). As if this chronic worrying weren't unpleasant enough, the majority of patients with GAD also suffer from comorbid major depressive disorder (APA, 2000; Kessler et al., 1999) and/or another anxiety disorder (APA, 2000; Carter et al., 2001). Irritable bowel syndrome is also common (Garakani et al., 2003).
There is strong research support for cognitive-behavioral treatments for GAD across the lifespan. In children, the Coping Cat 
(Kendall, 1994) tackles anxious thoughts, behavioral avoidance, and overarousal in children (ages 8-13). Several studies have promoted its effectiveness (see Weisz, 2004
, for a review). In adults, cognitive-behavioral, cognitive (mainly cognitive restructuring), and behavior therapy (mainly relaxation) have received empirical support (see the Society for a Science of Clinical Psychology's treatment website for a list of references). My focus for the rest of this article will rest on the treatment of GAD in older adults.
GAD in late life is common, with studies estimating prevalence up to 7.3% in the community (Beekman et al., 1998) and 11.2% in primary care (Tolin et al., 2005). Several studies have begun to examine the utility of cognitive and behavioral treatments for GAD in older adults. I find this area of research very interesting, because, as a society, we are taught that older people are "set in their ways" - that trying to get older people to change their thoughts and behaviors is futile. Furthermore, when you think about the chronicity of GAD, most older adults with GAD have literally been worriers almost their entire life. All of this makes many people believe that attempting a psychosocial intervention in an older population is at least difficult, if not impossible. But a host of literature is demonstrating that psychotherapy can be incredibly effective in mentally ill older adults for a variety of problems (e.g., depression). A new study by Melinda Stanley and colleagues published in the Journal of the American Medical Association examined the efficacy of cognitive-behavioral therapy in primary care for older adults (mean age = 66.9 years). Right of the bat, I was interested in their use of a primary care setting, where so many people, especially older adults, present first for treatment (see our Featured Article this month about the treatment of PTSD in recent combat veterans in primary care clinics). In the present study, 134 participants (minimum age 60) were randomly assigned to CBT or enhanced usual care. Diagnoses were made using a structured diagnostic interview. The only comorbid conditions that were excluded were active substance dependence, schizophrenia, and bipolar disorder. The CBT condition included "education and awareness, motivational interviewing, relaxation training, cognitive therapy, exposure, problem-solving skills training, and behavioral sleep management" (p. 1462; mean number of sessions = 7.4). The enhanced usual care condition received biweekly phone calls of 15-minute duration by therapists to provide support and ensure patient safety (mean number of phone calls = 4.3). Their primary outcomes were worry and GAD severity, and secondary outcomes were comorbid depressive and anxiety symptoms and general mental health. The results indicated significant improvements in worry, depressive symptoms, and general mental health in the CBT groups as compared to the control group. These improvements were maintained at a 3 and 15-month follow-ups. No differences were observed in the measure of GAD severity (the Generalized Anxiety Disorder Severity Scale).
The outcomes of this study are impressive and interesting. Clearly, they demonstrate that CBT is efficacious for the treatment of GAD in older adults in primary care clinics. Of course, these data need to be replicated and extended, but this study lays the groundwork nicely. However, it's essential to recognize that this data (and others) defy our communal belief that "you can't teach an old dog new tricks." Older adults should not be discouraged from seeking treatment for a mental illness, even if they have been living with it for a lifetime as many sufferers of GAD have. Research continues to offer hope that such suffering doesn't have to continue.
Treatment Manuals: CBT for GAD
- Clinical Handbook of Psychological Disorders, Fourth Edition: A Step-by-Step Treatment Manual (Barlow: Clinical Handbook of Psychological Disorders)
- Mastery of Your Anxiety and Worry (MAW): Therapist Guide (Treatments That Work)
Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.
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