Cognitive therapy versus applied relaxation as treatment of generalized anxiety disorder
Introduction
Although a very common and chronic problem in the general population (lifetime prevalence 4.1–6.6%, Blazer, Hughes, George, Swartz and Boyer, 1991, Kessler, McGonagle, Zhao, Nelson, Hughes, Eshleman, Wittchen and Kendler, 1994), generalized anxiety disorder (GAD) is not so frequently seen in mental health centers (e.g. approx. 4.3% of the patients from our center have GAD as a first diagnosis). Despite a relatively low prevalence of GAD at our center, we decided thirteen years ago to start a clinical trial, comparing what then seemed to be two of the most promising treatments for GAD, applied relaxation (AR) and cognitive therapy (CT). In the meantime, much more has become clear about the effects of various treatments for GAD.
Several studies have compared CT and cognitive-behavior therapy (CBT), based on the work of Beck and Emery (1985) with behavior therapy (BT) approaches (such as anxiety management training). In general, C(B)T was more effective than BT, especially in the long run (Butler, Fennell, Robson and Gelder, 1991, Durham and Turvey, 1987). CBT has also been compared to benzodiazepines, and proved to be more effective both in the short and in the long term (Power, Jerrom, Simpson, Mitchell and Swanson, 1989, Power, Simpson, Swanson and Wallace, 1990). A recently developed CBT package specifically focussing at worrying was only compared to a waitlist condition (Ladouceur et al., 2000). AR, a treatment approach developed by several workers (Bernstein and Borkovec, 1973, Öst, 1987) also fared well in various clinical trials (Barlow, Rapee and Brown, 1992, Borkovec and Costello, 1993), and has often been part of CBT programs (e.g. Borkovec and Costello, 1993, Power, Simpson, Swanson and Wallace, 1990). According to DeRubeis and Crits-Cristoph (1998), only C(B)T has proved to be effective and specific, whereas AR has been proved to be effective. Only three studies directly compared these two approaches. One found no statistically significant differences, but had low statistical power (Barlow et al., 1992). The second found no significant differences immediately after treatment, but at 12-months follow-up CT seemed superior to AR (Borkovec & Costello, 1993). The third found the two approaches equally effective (Öst & Breitholtz, 2000).
In a recent overview of six controlled trials, Fisher and Durham (1999), using the STAI-trait as common measure, compared seven psychological treatments of GAD. Individual AR and individual 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, group C(B)T and group BT were moderately effective (31–38% recovery at half year follow-up), and individual BT (11%) and analytical psychotherapy the least (4% recovery). Thus, the present study is helpful as an independent test of whether the good results of AR and C(B)T achieved in 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 other ‘unnatural’ ways, as has been done in the typical GAD treatment study (e.g. recently by Ladouceur, Dugas, Freeston, Léger, Gagnon and Thibodeau, 2000, Öst and Breitholtz, 2000). Two of the three previous studies directly comparing AR and CT for GAD used advertisements to recruit subjects (Borkovec and Costello, 1993, Öst and Breitholtz, 2000). By contrast, the GAD patients in the present study were not especially recruited for 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 study most comorbid diagnoses were allowed, and many patients indeed had comorbid diagnoses. A third threat to validity is the investigation of a treatment developed by the researchers. The finding that researchers-alliance is related to stronger effects of the pertinent treatment, also called the “allegiance-effect”, is not uncommon (McNally, 1996). Independent replication is the best safeguard against this bias (in general, independent replication is the most essential, but sometimes undervalued, verification tool in science). A relevant example are three studies each comparing Clark and Salkovskis’ CT for panic disorder with Öst’s AR package in the treatment of panic disorder. Clark and coworkers found CT to be superior to AR (Clark et al., 1994), whereas Öst’s group found AR and CT equally effective (Öst & Westling, 1995). An independent replication 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). Öst’s AR as treatment for GAD has only been investigated by its developer and a coworker (Öst & Breitholtz, 2000). Thus, an independent replication 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 and CT, with respect to their immediate and long-term effects, in a sample of GAD patients representative of the clinical population. The study is comparable to the study by Öst and Breitholtz, 2000, who compared the same treatment approaches. Although the comparison is not new, the present study is valuable as an independent test, not biased by possible allegiance-effects, and because the investigation was done in a clinical sample of non-recruited patients with high rates of comorbidity. Anxiety complaints, trait anxiety (notably heightened in these patients, cf. Fisher & Durham, 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 different outcome studies. Their norms enable the results of the present study to be compared with those of other studies.
Section snippets
Patients
Patients of the Community Mental Health Center at Maastricht who were referred to the Academic Section Behavior Therapy participated if they met the following criteria: (1) primary diagnosis of GAD; (2) requesting treatment for their GAD; (3) older than 17 and younger than 70 years; (4) no depressive disorder preceding the current episode of GAD or requiring immediate treatment; (5) no behavior therapy received for their GAD; (6) no evidence of organic mental disorders accounting for the
Pretest differences
Two significant differences were found: 4 of the 25 CT subjects had no partner, as compared to 9 of the 20 AR subjects, Fisher’s Exact Test p=0.032; and educational level was lower in the AR condition than in the CT condition, t(43)=2.57, p=0.014. There were no differences between the groups on other variables, including sex, age, work situation, duration of complaints, number of diagnoses, medication use, pretest panic frequency and pretest composite questionnaire score.
Drop-outs
There were five
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 most effective treatments for GAD, AR and CT. By and large, both approaches seemed equally effective. As recovery rates and rates of clinically significantly change are comparable to those found in other studies (Fisher and Durham, 1999, Öst and Breitholtz, 2000), the lack of difference between AR and CT does not
Acknowledgements
Gillian Butler and Lars-Göran Öst are acknowledged for their help in preparing the study. The centers’ research assistants are acknowledged for their help in acquiring, scoring and entering the data. The therapists are thanked for treating the patients of this study. Gillian Butler gave valuable comments on a previous version of this report.
References (34)
- et al.
Psychological treatment of panic disorder without agoraphobia: cognitive therapy vs. applied relaxation
Behaviour Research and Therapy
(1996) - et al.
Treatment of childhood memories: theory and practice
Behaviour Research and Therapy
(1999) - et al.
Behavioral treatment of generalized anxiety disorder
Behavior Therapy
(1992) - et al.
Generalized anxiety: a controlled treatment study
Behaviour Research and Therapy
(1987) Generalized anxiety disorders publications: so where do we stand?
Journal of Anxiety Disorders
(2000)- et al.
Cognitive therapy vs. behaviour therapy in the treatment of chronic general anxiety
Behaviour Research and Therapy
(1987) - et al.
Brief Standard self-rating scale for phobic patients
Behavior Research and Therapy
(1979) Applied relaxation: description of a coping technique and review of controlled studies
Behaviour Research and Therapy
(1987)- et al.
Applied relaxation vs. cognitive therapy in the treatment of generalized anxiety disorder
Behaviour Research and Therapy
(2000) - et al.
Applied relaxation vs. cognitive behavior therapy in the treatment of panic disorder
Behaviour Research and Therapy
(1995)
A controlled comparison of cognitive-behavior therapy, Diazepam and Placebo, alone and in combination, for the treatment of generalised anxiety disorder
Journal of Anxiety Disorders
Generalized anxiety disorder: a review of clinical features and theoretical concepts
Clinical Psychology Review
Dimensional structure, reliability and validity of the Dutch version of the Symptom Checklist (SCL-90)
Nederlands Tijdschrift voor de Psychologie en haar Grensgebieden
Anxiety disorders and phobias: A cognitive perspective
Progressive relaxation training
Generalized anxiety disorder
Efficacy of applied relaxation and cognitive-behavioral therapy in the treatment of generalized anxiety disorder
Journal of Consulting and Clinical Psychology
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