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Cognitive Behavioral Treatment of Generalized Anxiety Disorder

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Generalized Anxiety Disorder Case Study: James

A paper on case studies.

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Generalized anxiety disorder, (GAD) is a traumatic illness, and is hard to understand unless you are experiencing it yourself. While specific anxiety disorders are complicated by panic attacks or other features of the disorder, GAD has no specific focus. (Durand, 2007 p.130). The person constantly worries about everyday life; not being able to figure out what to do with their worries. All the while making themselves and everyone around them miserable. (p.130). The worries seem to take over control of one's life, almost to the point of not being able to function at all.

It seems that GAD tends to run in families based on studies conducted, and seems to happen more to women than men. (Durand, 2007 p.132). And evidence shows that GAD may be proved to be just as heritable, the same as other anxiety disorders. (p.133). The textbook states that this disorder originated in 1980, however therapists were working with patients with anxiety way before the criteria was developed. (p.133). For many years, clinicians believed that people who were generally anxious just didn't seem to have anything specific to focus on, thus calling it the 'free floating' disorder. (p.133).

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) has specific criteria that characterized GAD. As stated in our textbook, the features are:

• Excessive anxiety and worry for 6 months or more about a number of events or activities. • Difficulty in controlling the worry. • At least three of these symptoms: (1) restlessness of feeling all keyed up; (2) becoming fatigues easily; (3) difficulty concentrating; (4) irritability; (5) muscle tension; (6) sleep disturbance. • Significant distress or impairment. • Anxiety is not limited to one specific issue. (Durand, 2007 p.131).

Generalized anxiety disorder has been studied using various criteria. The National Comorbidity Survey (NCS) focused on noninstitutionalized American civilians ages 15 to 54. The results were reported and found there was a clear predominance of women with GAD, with a 2:1 female/male ratio. It was lowest among the younger age group but increased with age. (NA, 1997). 'There was a significant regional difference in GAD as well, with a higher lifetime prevalence in the Northeast than in other parts of the country.' (1997). Studies have shown that many people could not really pinpoint a clear age of onset of GAD or an onset dating back to childhood. (Barlow, 1993 p.156). There have also been twin studies which conclude that GAD is somewhat greater for identical female twins than for non-identical twins, but only if one twin already had generalized anxiety disorder. (Durand, 2007 p.132). But later researched showed that what seemed to be inherited was the ability to become anxious rather than GAD itself. (p.132). It's amazing to know that people with GAD seem to show less responsiveness on most physiological measures, such as heart rate, blood pressure, skin conductance and respiration rate than do people with other anxiety disorders. (p.133).

Although it seems to prove that GAD is quite common, I am amazed that more people don't have this disorder. I think that many people have general anxieties on a daily basis, but most people are able to handle them successfully. I did not realize that most people with GAD have usually had symptoms of anxiety or feelings of being worried throughout life, but just didn't know when it all started. The criterion has changed over the years as well as doctors have become more knowledgeable about this disorder. I first had knowledge of this disease in 1997 when I noticed strange things happening.

He was not really watching as he stared directly at the television set. I would notice that he had no expressions at all; nothing during the humorous scenes, or the dramatic ones. He once told me that it was as if he was someone else, watching himself try to crawl out of his own skin. That was 10 years ago when I was married to this man who was suffering from generalized anxiety disorder. I didn't understand and I really didn't want to. I thought he was just being lazy and unmotivated. Although this disorder seems to be simple to others, it is quite alarming to the person who is suffering from it, and the onset is rather quick, whereas, treatments are difficult. Everyone experiences anxiety, but in most people, it does not last for months at a time.

The case study I am choosing is about James who is a doctor suffering from generalized anxiety disorder. At 31 years of age and living in New York, he is unemployed because of his constant anxiety, even at the thought of working. He now lives with his parents off a small trust fund set up for him by an uncle. Although he was an overachiever throughout his academic career, James is having a hard time keeping it together, while his parents are somewhat supportive but disappointed with his medical career. Let's see what we can learn about this horrible and crippling disorder. 'Generalized anxiety disorder is associated with irregular neurotransmitters in the brain. Neurotransmitters are chemicals that carry signals across nerve endings. Neurotransmitters that seem to involve anxiety include norepinephrine, GABA (gamma-aminobutyric acid), and serotonin.' (na, 2001). So it was thought that reduced levels of GABA initiated excessive anxiety, although neurotransmitters are much to complex to be interpreted that simply. (Durand, 2007 p.45).

The brain is a very fascinating and intricate part of who we are and if the brain is not functioning properly, then our reactions to certain situations are not in balance. This is why some people still believe that undeniable psychological disorders are said to be caused by biochemical imbalances. (Durand, 2007 p.50). So in James' case, his brain was not functioning right and he was experiencing an unnatural balance of change within his various neurotransmitters, causing him to become anxious, easily irritated, distracted and quite tense. He also complained of headaches, body aches and pains and always feeling tired.

Genetics does play a major role is determining whether a person will or will not have a psychological disorder. The textbook states that the research is beginning to acknowledge genes that relate to some psychological disorders. (Durand, 2007 p.70). I feel that genetics does contribute to some disorders, but I also think that the environment and society can cause debilitating stress to induce certain disorders, such as anxiety. If the gene linked to the disorder is dormant, a stress related incident can bring it to the surface, thus bringing on the disorder. My research has shown that there are brain abnormalities indicated with generalized anxiety disorder. A study of 30 patients displayed that compared to 20 healthy volunteers, 11 patients had significant brain abnormalities mainly in the right temporal lobe. (Nutt, 2003 p.209). The temporal lobe controls the processes of recognizing various sights and sounds and long term memory storage. (Durand, 2007 p.48). However there are two temporal lobes on each side of the brain, located at the level of the ears. The lobes help a person distinguish one sound from another as well as one smell from the other. The right lobe controls visual memory while the left lobe controls verbal memory. (Johnson, 2006) So this would explain why James kept making mistakes because he was probably having a hard time remembering simple procedures.

The first thing James would need to do would be to seek professional help and see if he has this disorder, although being a medical doctor, he may have self diagnosed himself, however he should see a psychiatrist. There are no laboratory tests that can determine if a person has anxiety or a mental illness, but a doctor will perform a battery of tests to weed out other illnesses, such as an overactive thyroid gland, which can produce anxiety and its symptoms. (NA, 2007 WebMD). James' next plan of attack would be to discuss the different types of medications that are available for providing relief from this disorder. Since James has generalized anxiety disorder, which has been called a 'free-floating' disorder because of his constant worrying and nervousness, as stated earlier, he would need a medication that treats low levels of GABA. (Roberts, ch.17 p.6). The textbook states that the drub benzodiazepine (minor tranquilizers) is the most frequently prescribed. (Durnad, 2007 p.134). The drug is used for short-term relief and can be hard to stop taking because of dependence issues. One such drug in particular is called Xanax, which is shown to enhance the function of GABA in the brain. It also slows down the central nervous system. This drug is extremely addicting; it's the drug my ex-husband did not want to give up, so we got a divorce.

There is also evidence that antidepressants can be used for GAD and may be a better choice. (p.134) The most common antidepressants are prozac and zoloft. 'These drugs are shown to affect the concentration and activity of the neurotransmitter serotonin, a chemical in the brain thought to be linked to anxiety disorders.' (na, 2004). Some of these drugs that I have researched for GAD, are also used for treating migraines, because I was prescribed some for headaches. No wonder I was always in a good mood, even though it felt like my head was about to explode.

Because the drugs prescribed for this disorder are recommended to be taken for short periods of time, therapy should be initialized as well. The side effects of these drugs are: Xanax (benzodiazepines): drowsiness, fatigue, decreased concentration, confusion, blurred vision, pounding or irregular heartbeat, impaired coordination, short term memory problems, dizziness. (Smith et al, 2006).

Prozac (Selective Serotonin reuptake inhibitors): nausea, insomnia, headaches, decreased sex drive, dizziness, weight gain or loss, nervousness, sweating, drowsiness/fatigue, dry mouth, diarrhea or constipation, skin rashes. (Smith et al, 2006) These medications offer so many side effects, it's a wonder anyone wants to take them at all. But I guess for the person who is suffering from anxiety attacks or generalized anxiety disorder, the side effects may be a welcomed relief There are also natural remedies to help with GAD such as valerian root and kava kava, which has been treating anxiety for years, but the results are not well documented. (Smith et al, 2006) Some natural remedies can actually make anxiety worse and taking supplements may interact with the prescription anxiety medications, so it's a good idea to discuss this with a doctor.

Another approach to treatment is to help James with therapy sessions to try to figure out why he is experiencing all this anxiety and worry. One session may include showing James pictures of things that may make him anxious and then teaching him how to relax deeply to fight his tension. It's called cognitive behavioral treatment, developed in the early 1990s, and is quite successful; however we need both medications and therapy to treat GAD. (Durand, 2007 p.134).

Acupuncture, which is one medical treatment that does no harm to the body, only releases energy and gets it moving in the system; (NA, 2007) biofeedback, which is the ability to allow the patient hear or see feedback of their body's physiological state while relaxing;(Grohol, 2004) and hypnotherapy shown as an appropriate treatment modality for those individuals who are highly suggestible, have also been used to treat anxiety. (Grohol, 2004).

So which treatments work the best? That is hard to say because everyone is different and will react differently to each treatment. As stated in the textbook, a combined treatment of therapy and medications suggested there were no advantages for both, and that people did better in the long run when having psychological treatments only. (Durand, 2007 p.144). So it's suggested to start with psychological treatment first and then followed by drug treatments for the patients who are not responding to therapy. (p.144).

How does environment influence our behavior? Do we imitate what we see around us? Are we simply looking for acceptance, thereby, acting or saying what we think society expects? Who decides what acceptable behavior is? Although the environment may affect a person's behavior, there are many other elements to explore that influence the way we are.

James is coping with generalized anxiety disorder, as was stated earlier. At 31, he is allowing this disorder to control his life which is leading to being emotionally and physically drained. Although he realizes that he is an intelligent and capable person, he knows to avoid any situation that may exacerbate the anxieties that he is experiencing. With minimal support from his family and friends, James feels that he is dealing with this all alone and just wants to lead a normal life. Perhaps the stress and strain of becoming a doctor led to James' anxiety disorder as it may have been dormant within his genetic makeup, and is now just surfacing.

Many people develop generalized anxiety disorder (GAD) during adolescence, but do not seek professional help until they are adults. (NA, 2001). When they do finally get help, they claim they have been anxious and nervous all their lives. (2001). These people cannot just 'get over it' but society seems to not grasp that concept. Some of the environmental influences that could lead to general anxiety are: • Work. This would affect James immensely because his whole life has been based around his becoming a doctor. Even his father wanted him to follow in his footsteps and have a prestigious career. • School. Although James did not experience anxieties until after he graduated from medical school, I'm sure he still felt anxious with tests and schoolwork. • Relationships. This would be dealing with James' parents as they are somewhat supportive but disappointed that his career has not been progressing. He also lost his relationship with his girlfriend of three years because of the stress. • Health. Because James is dealing with this disorder, his health is rapidly declining. He is having headaches, body aches and pains and is always tired. His emotional health is affected as well with feelings of laziness and worthlessness. • Financial. James is realizing that if he cannot work, he cannot earn a paycheck. He is living off a small trust fund set up for him by his great uncle, but that won't last forever. All of these things are considered threats and can cause James to worry excessively which is interfering with his life.

Is the environment to blame for James' anxiety or is it more biological? I think that genetics and the environment work together to produce this disorder. I feel that if a person is genetically prone to have anxiety and fear; if the person never leaves the house, then what does he/she have to worry about? The environment has to play a role in the mobility of this disorder. If James were to isolate himself from the world, he would still have anxiety; however he would not be able to face his fears, thus restricting his life. His thought process would be 'what if this happened, or what if that happened?' He would always be having threatening thoughts and images playing over and over in his mind. (Alloy, 2006 p.189).

Our textbook states that GAD generally runs in families, which I mentioned earlier. (Durand, 2007 p.132). With all the research and studies that are performed, it will show that generalized anxiety disorder is inherited. So genetics and biology has to be the most important because people who aren't suffering from anxiety will react more favorable to a stressful situation, than someone who is suffering from GAD. It seems that we all have to face the same environmental influences, but the threat of each situation interacts with the biological aspect of a person, thus bringing on the symptoms of the disorder. (p.133).

James needs to be treated by a psychiatrist, not a family physician. He needs to be seen by someone who deals with psychological disorders daily and is educated with the treatments available. Psychological treatments work better in the long run and work just as well as prescription medication. Our textbook states that, 'as we learn more about generalized anxiety, we may find that helping people with this disorder to focus on what is actually threatening is useful.' (Durand, 2007 p.134).

Research has indicated that psychological treatments work very well for children who suffer from GAD. (Durand, 2007 p.135). But I feel that unless a child is diagnosed early in life, the treatments won't be as effective. I'm sure that James was experiencing some form of anxiety as a child, but children are difficult to diagnose, and if the parents don't know what to look for, they won't know the child needs help. But children respond to cognitive-behavioral treatments along with family therapy. (p.135).

I feel that psychosocial treatments would be the best way to start with a patient. In James' case, I think he should start with therapy for at least three months. He needs to confront the fear, phobias and anxieties head on to figure out what's making him feel emotionally and physically drained. I would also suggest to James that he should educate and read everything he can on this disorder. Having this knowledge will benefit him so he may get the most out of his treatments. If I had a disorder, I would want to know everything about it. And I would be asking a million questions. Sometimes I feel that everyone in society could use some form of therapy to deal with the stressors of life.

Next, I would try medications in addition to therapy to help James with possible other symptoms of GAD, such as depression. (Smith et al, 2006). The medication, however, would only be used on a temporary basis, as addiction can occur. My ex-husband was on medication for his GAD, but he was not seeing anyone for therapy. I think that was the biggest problem. He was increasing his dosage without telling his doctor, thus becoming extremely dependent on the drugs. As a doctor, James should know that some of the medications used for GAD are very addictive and hopefully would only be used as directed.

There are certain beliefs about thoughts and thought processes that are included in cognitive forms. (Papageorgiou, 2004 p.228). 'There are two types of worries; Type 1 and Type 2. Type 1 worries deal with external daily events such as the welfare of a partner, and non-cognitive internal events such as concerns about bodily sensations. Type 2 worries are focused on the nature and occurrence of thoughts themselves such as worrying that worry will lead to insanity. It's basically worry about worry.' (Wells, 1997 p.202). The cognitive model claims that the varieties of worry are typically type 2 worries in which the patients negatively appraise the activity of worrying. (p 202). I feel that the cognitive psychological model best applies to understanding and treating this disorder. I believe that by using cognitive therapies and similar research studies, we can begin to know what it takes to treat the people who are suffering with better results now and in the future. There are new medications that can help people with GAD, but there are side effects that may be too harsh or severe. I believe that more psychosocial therapies may need to be developed in order to help these people, so they can live a normal life without medications, because of the problems they present to the body.

I believe that James could once again become a successful doctor if and when he gets his generalized anxiety disorder under control. The treatments are available; all he has to do is seek them out. I feel that with therapy coupled with medications would benefit James tremendously. Eventually he will be able to stop taking the medications and perhaps enjoy a fairly normal life. The good news is that only 4% of the population meets the criteria for GAD during a given one-year period. However it is still one of the most common anxiety disorders. (Durand, 2007 p.132). . My research for this paper has helped me so far in understanding what a person is going through with crippling anxiety. It's not something that a person can just 'get over' and I know I wanted to tell my ex-husband that many, many times. However, he became addicted to the prescriptions drugs, and became a drug addict in about two weeks. Because of my first hand experience with this disorder, I chose to do my projects on it.

References N.A. (1997) Retrieved Oct. 20, 2007 from The Natural History of Generalized Anxiety Disorder website: www.medscape.com N.A. (2001). Retrieved Sept. 16, 2007 from General Anxiety Disorder website: http://www.mentalhealthchannel.net N.A. (2004). Retrieved Sept. 13, 2007 from Anxiety Disorders Association of America website: http://www.adaa.org N.A. (2007) Retrieved Sept. 17, 2007 from Anxiety Panic Guide website: http://www.webmd.com N.A. (2007). Retrieved Oct. 21, 2007 from Acupuncture for Generalized Anxiety Disorder website: www.revelutionhealth.com Barlow, D. (1993) Clinical Handbook of Psychological Disorders: A step-by-step treatment Manual 3rd ed. Guilford Press Retrieved Oct. 20, 2007 from libsys.uah.edu. Durand, V. & Barlow, D. (2007) Essentials of Abnormal Psychology: Mason, OH. Thomson/Wadsworth Publishing. Grohol, J. (2004) Retrieved Oct. 20, 2007 from generalized anxiety disorder treatment website: www.psychentral.com/disorders Johnson, G. (2006) Retrieved Sept. 15, 2007 from A Guide to Brain Anatomy website: http://www.waiting.com/brainanatomy Nutt, D. & Ballenger, J. (2003). Anxiety Disorders. Malden, Ma: Blackwell Publishers Retrieved Sept. 18, 2007 from Net library search: libsys.uah.edu Papageorgiou, C. & Wells, A. (2004). Depressive Rumination Nature, Theory and Treatment. Hoboken, NJ: John Wiley & Sons, LTD. Roberts, M. (nd). Introductory Guide to Psychology Kaplan University Class SS-124 Alloy, L. & Riskind, J. (2006). Cognitive Vulnerability to Emotional Disorders. Mahwah, NJ: Lawrence Erlbaum Associates Inc. Smith, M., Kemp, G., Larson, H., Jaffe, J., Segal, J. (2006). Retrieved Oct.8, 2007 from Anxiety Attacks and Disorders website: http://www.helpguide.org Wells, A. (1997). Cognitive therapy of Anxiety Disorders: A practice manual and conceptual guide. Chichester, NY: John Wiley & Sons, LTD.

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• v.176(4); 2002 Sep

Case-Based Reviews

Anxiety disorders, jian-ping chen.

1 Charles B Wang Community Health Center 125 Walker St New York, NY 10013

Leonard Reich

2 Health Insurance Plan of Greater New York 7 West 34th St New York, NY10001

Henry Chung

3 Pfizer, Inc. 235 East 42nd St. New York, NY 10017

see also p 239, 257

Summary points

• Careful evaluation of an anxious patient will help to determine if thecause of the anxiety is organic or psychological
• Use of herbal and over-the-counter substances should be determined becausesome herbal products (eg, ginseng, ma huang , and certain coughmedicines) contain stimulants that cause symptoms of anxiety
• Anxiety is often associated with one or more other mood disorders that mayrequire management and treatment
• Primary care practitioners should incorporate psychological techniques intheir medical management of Asian patients with anxiety

Ms M is a 60-year-old widowed Chinese woman with a 6-month history ofepisodic chest tightness, shortness of breath, pain that “moves all overmy body,” and numbness in her legs. These attacks, which occur once ortwice weekly, occur suddenly, reaching peak intensity within a few minutes.During an attack, pain travels from her chest to her abdomen, groin, and legs.The pain is often accompenied by a sensation of intermittent “hotQi” (air) coming from her abdomen to her throat, making her believe thatshe is being choked. She also describes feeling as if she is in a closed roomor small space. Ms M is anxious and frustrated about her symptoms and thinks she might havea serious medical problem. She has had frequent medical evaluations by herprimary care physician and second opinions from various specialists. Ms Mconsulted a doctor of traditional Chinese medicine and tried some herbalmedications, but has had no relief. She has refused to see a psychiatrist.

ANXIETY DISORDERS IN THE PRIMARY CARE SETTING

Anxiety disorders are a group of mental disturbances characterized byanxiety as a core symptom. In this article, we discuss anxiety disorderscommon to primary care, specifically panic disorder, generalized anxietydisorder (GAD), and posttraumatic stress disorder (PTSD).

The diagnosis is made when the constellation of symptoms are consistentwith the diagnostic criteria for each disease listed in the Diagnostic andStatistical Manual of Mental Disorders, 4th edition (DSM-IV) (see Tablelinked to this article on our web site). When symptoms of anxiety becomepervasive, have signs and symptoms consistent with DSM-IV criteria, and affectthe patient's ability to function, the presumed diagnosis is an anxietydisorder.

Which organic illnesses can cause anxiety symptoms?

Some of the disease states associated with prominent anxiety are shown in box 1 . These diseases, however,are rare explanations for anxiety and anxiety disorders. Clinicalinvestigations to identify a particular disease entity should only beundertaken if the pre-test probability of the disease is high.

Disease states associated with anxiety

What features are suggestive of an organic cause of anxiety?

An organic cause of anxiety should be suspected when the onset of symptomsis sudden, changes have recently occurred in the patient's medication, or thepatient has specific signs and symptoms suggestive of a new organic diseaseprocess.

When a patient presents with anxiety, the following features should promptclinicians to suspect an underlying nonpsychiatric disorder is thecause 1 :

• Onset of anxiety symptoms after the age of 35
• Lack of personal or family history of an anxiety disorder
• Lack of childhood history of significant anxiety, phobias, or separationanxiety
• Absence of significant life events generating or exacerbating the anxietysymptoms
• Lack of avoidance behavior
• Poor response to anxiolytic agents

How do you evaluate an anxious patient?

The medical evaluation of anxious patients should include a completehistory and physical examination. Features of the history that merit specialattention are:

• Substance use/abuse (eg, caffeine, amphetamines, marijuana, cocaine) andwithdrawal (eg, from alcohol or sedative-hypnotics)—both of these cancause anxiety symptoms
• Use of medications with anxiogenic effects (β-adrenergic agonists,theophylline, corticosteroids, thyroid hormone, sympathomimetics,psychostimulants)

Asking Asian patients if they are using any herbs or medicines given byfriends or relatives is important because some may contain ma huang (a stimulant) or ginseng. These substances may cause or exacerbate anxiety(see below).

Laboratory and medical tests should be performed only as indicated bysymptom constellation and clinical judgment.

Which cultural issues are important to consider?

Issues that are important in diagnosing anxiety include the following:

• Many Asian patients do not use the word anxiety. Instead, they discuss“nervousness,” “tension,” or “beingtense”
• Because being anxious is viewed as being weak or incompetent, many Asianpatients with anxiety disorders tend to present with physical complaints. Aphysical problem often is seen as a more legitimate reason to get help and togain sympathy and support from family members and friends
• Many patients with anxiety disorders also have depression. As many as 50%of patients with anxiety will have an episode of major depression at some timein their life 2
• Often patients may understand their symptoms as a defined illness that isknown only to the specific native culture. Examples include neurasthenia (a“nerve weakness,” see p 257), pa-leng (Chinese for“fear of cold”), hwa byung (Korean for “fireillness”) and taijin kyofusho (Japanese for “fear oflosing face and facing situations)
• Psychosocial issues encountered by new immigrants can exacerbate or createnew anxiety
• Some Chinese pharmaceuticals can cause or worsen anxiety. Ma-huang contains ephedrine, a common ingredient in cold medication or diet pills,which increases heart rate, blood pressure, and sweating, all markers ofanxiety. Ginseng possibly increases the basal metabolic rate and increasesheart rate, which may trigger anxiety

Treating anxiety with medication may be consistent with an Asian patient'sview that anxiety is a medical issue rather than a psychological one. Inaddition, adherence to a medical regimen hinges less on a good language matchbetween patient and physician than would be the case with a psychologicaltreatment program. Medication also has the benefit of relieving distressingphysical symptoms and rapidly returning patients to pre-existing functionallevels.

A major limitation of treating anxiety with medication alone is thatpatients do not evaluate their conditioned patterns, coping strategies, orenvironmental circumstances, which may be the root cause of their anxietydisorder. Failing to address these issues increases the risk of relapse whenmedication is discontinued.

Therefore, clinicians in primary care settings should emphasizepsychological treatments with the same conviction as medical ones. Researchfindings show thatpsychopharmacologic 3 , 4 and cognitive behavioralpsychotherapeutic 5 , 6 , 7 interventions individually are effective in the treatment of approximately 60to 90% of patients with various forms of anxiety disorders. The combination ofmedication and psychotherapy produces the most effective long-termresults. 8 , 9 , 10

SPECIFIC DISORDERS

Panic disorder, clinical assessment.

We have found that some Asian patients present with panic attacks that havestrong cultural overtones, characterized by only one or two predominantclassic symptoms. Our Chinese American patients with anxiety commonly complainof “hot and cold” symptoms (such as pa-leng ). Despite aconsistent environment, they describe sensations of hot or cold Qi (air) going up and down their body, along with other bodily discomforts.

“ Hwa byung ” is also a common cultural idiom ofdistress seen in Koreanpatients. 11 Lin andcolleagues describe this syndrome as highly somatized with anxiety, insomnia,sensations of heat in the body and the impulse to “get out of thehouse.” 11 Patients with these symptoms often recognize that the symptoms arepsychological and result from suppressing anger.

Obtaining a brief history of the patient's experience with panic attacks isuseful because panic attacks and agoraphobia (fear of being placed insituations where obtaining help is difficult, such as lonely open spaces ortraveling alone) may seriously limit the patient's ability to travel toappointments and comply with aftercare. If panic disorder with or withoutagoraphobia is diagnosed in Asian patients, time may be required to assesspatients' travel patterns and their ability to travel beyond their immediatecommunity.

Psychological treatments

Psychological treatments for panic have proven effective both independentlyand as an adjunct to medication. In a recent randomized controlled trial,investigators compared the effectiveness of cognitive-behavioral therapy,imipramine, or their combination, against placebo in the treatment of panicdisorder. 12 Eachtreatment individually was better than placebo, and the combination treatmentwas more effective than individual treatments at preventing relapse.

Cognitive-behavioral therapy is the psychological treatment of choice forpanic disorder. A protocol developed by Barlow and Craske, which involvesexposure, cognitive restructuring, breathing retraining, and relaxationtraining ( box 2 ), has beenwell-validated. 13 We have found these treatments are effective in Asian American patients, yettheir use may be limited by a lack of bilingual therapists.

Psychological therapies for panic disorder

Suggestions for practitioners

• Provide a medical explanation that gives patients an understanding of theirphysical symptoms. Acknowledge that the symptoms are physical but are notrelated to a serious medical condition, such as heart disease
• Instruct the patient on how to use abdominal breathing (breathingretraining) at the first sign of hyperventilation, anxiety, or a panicattack
• Suggest that the patient use relaxation techniques
• Encourage the patient to practice breathing retraining and relaxationtechniques during non-panic anxiety states
• Provide helpful literature and/or relaxation tapes that reinforcerelaxation techniques

Generalized anxiety disorder (GAD)

Generalized anxiety disorder is defined as excessive anxiety or worry inthe absence of, or out of proportion to, situational factors. The symptoms ofthis disorder are restlessness or feeling on edge, being easily fatigued,difficulty concentrating or the patient's mind going blank, irritability,muscle tension, and sleep disturbance. The diagnosis requires that symptomshave been present for more than 6months. 14

Pharmacotherapy

The treatment of GAD is similar to treatment for all other anxietydisorders. A selective serotonin reuptake inhibitor (SSRI) may be administeredat low doses and adjusted upward for a full therapeuticresponse. 4 Psychotherapy for patients with GAD has not been well studied.

Posttraumatic stress disorder (PTSD)

Posttraumatic stress disorder occurs after exposure to an event involvingdeath, serious injury, or a threat to the physical integrity of self orothers. Patients with the condition persistently re-experience the event, suchas through dreams and flashbacks; show persistent avoidance behavior, such asdiminished involvement in usual activities or relationships; and persistentsymptoms of increased arousal, such as irritability andhypervigilance. 14 Events that trigger the disorder include war; torture; natural disaster;violence to self or others, including rape; serious illness; surgery; andevents that have an idiosyncratic impact on a given patient.

Immigrants from the Pacific Rim may be at a higher risk of having beenexposed to traumatic events related to their journey to the United States orto their reasons for wanting to leave their home country. For example, someimmigrants from China have been tortured for political reasons or sufferedfrom enforcement of birth control policy resulting in forced terminations ofpregnancies. The prevalence of PTSD is high among Southeast Asianrefugees. 15

Posttraumatic stress disorder is often associated with depression, otheranxiety disorders, and substance abuse. Clinicians should assess for theseother conditions in patients with PTSD because substance abuse and depressionincrease suicidal risk. The National Women's Study found that 31% of women whoare raped develop PTSD and that 13% of rape victims make a suicideattempt. 16

The treatment of choice for PTSD is SSRI medication and cognitivebehavioral psychotherapy, along with therapy for any associated psychiatricillness, such as depression.

• If you suspect that a patient has PTSD, assess for substance abuse. Ifpatients are abusing or misusing substances, you should explain what resourcesare available to help them and discuss the particular risks of using drugsthat may cause dependence, such as short-acting benzodiazepines
• Encourage patients to use relaxation techniques
• Explain that the physical symptoms they experience are common to manypeople who have experienced a traumatic event. One statement might be:“Sometimes symptoms such as chronic fatigue, headaches, and stomachaches are the body's communication for posttraumatic stress”
• Identify feelings such as fear, anger, guilt, and helplessness, which mighthelp to alleviate the patient's physical symptoms

When Ms M experienced an attack of severe pain in the office of her primarycare practitioner, her physician contacted a psychiatrist for an immediateconsultation. The psychiatrist rendered the diagnosis of panic disorder andrecommended a treatment regimen involving an antidepressant agent, abenzodiazepine, and biweekly supportive and cognitive therapy. After 3 monthsof therapy, Ms M no longer had symptoms. The dosage of the benzodiazepine was tapered and she continued to be wellfor another 6 months while taking the antidepressant alone. Belleving that shewas cured, Ms M then discontinued the use of the antidepressant against theadvice of her psychiatrist. Two months later, her symptoms recurred and sheresumed taking the antidepressant. ​ antidepressant. Table 3 DSM-IV diagnostic criteria for anxiety disorder Panic disorders Rapid onset of fear, terror, or discomfort PLUS at least four of thefollowing: Palpitations Sweating Trembling or shaking Shortness of breath Choking Chest pain or tightness Nausea Hot flashes or chills Dizziness or lightheadedness Fear of dying or going crazy Feelings of unreality or depersonalization Generalized anxiety disorder Excessive anxiety and worry (apprehensive expectation occurring more daysthan not for at least 6 months) about events or activities, such as work orschool performance The patient finds it difficult to control the worry Anxiety and worry are associated with three or more of the followingsymptoms (at least one of which must be present more days than not for the 6months); Restlessness or feeling keyed up or on edge Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance (difficulty falling or staying asleep or restlessunsatisfying sleep) The focus of the anxiety and worry is not about having a panic attack,social phobia, obsessive-compulsive disorder, separation anxiety, gainingweight, having multiple physical complaints, or having serious illness; itnoes not occur exclusively during posttraumatic stress disorder Anxiety, worry, or physical symptoms cause clinically significant distressor impairment in social, occupational, or other important areas offunctioning The disturbance is not due to the direct physiologic effects of a substanceor a general medical condition and does not occur exclusively during a mood,psychotic, or a pervasive developmental disorder Posttraumatic stress disorder The person has been exposed to a traumatic event in which both of thefollowing were present: The person experienced, witnessed, or was confronted with an event orevents that involved actual or threatened death or serious injury or a threatto the physical integrity of self or others The person's response involved intense fear, helplessness, or horror. Inchildren, this may be expressed instead by disorganized or agitatedbehavior The traumatic event is persistently re-experienced in one (or more) of thefollowing ways: Recurrent and intrusive distressing recollections of the event, includingimages, thoughts, or perceptions. In young children, repetitive play may occurin which themes or aspects of the trauma are expressed Recurrent distressing dreams of the event. Children may have frighteningdreams without recognizable content Acting or feeling as if the traumatic event were recurring (includes asense of reliving the experience, illusions, hallucinations, and dissociativeflashback episodes, including those that occur on awakening or whenintoxicated). In young children, trauma-specific reenactment may occur Intense psychological distress at exposure to internal or external cuesthat symbolize or resemble an aspect of the traumatic event Physiologic reactivity on exposure to internal or external cues thatsymbolize or resemble an aspect of the traumatic event Persistent avoidance of stimuli associated with the trauma and numbing ofgeneral responsiveness (not present before the trauma), as indicated by three(or more) of the following: Efforts to avoid thoughts, feelings, or conversations associated with thetrauma Efforts to avoid activities, places, or people that arouse recollections ofthe trauma Inability to recall an important aspect of the trauma Diminished interest or participation in significant activities Feeling of detachment or estrangement from others Restricted range of affect (eg, unable to have loving feelings) Sense of a foreshortened future (eg, does not expect to have a career,marriage, children or a normal life span) Persistent symptoms of increased arousal (not present before the trauma) asindicated two (or more) of the following: Difficulty falling or staying asleep Irritability of outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response Duration of the disturbance is more than 1 month. The disturbance causes clinically significant distress or impairment insocial, occupational, or other areas of functioning The condition is: Acute if duration of symptoms is less than 3 months Chronic if duration of symptoms is 3 months or more With delayed onset if onset of symptoms is at least 6 months after thestressor Open in a separate window

Dwarf ginseng ( Panax trifolius L.). The physiologic effects ofginseng may trigger or worsen anxiety

ROC/Taiwan Government Information Office

Difficulty concentrating and muscle tension are common signs of generalizedanxiety disorder

Competing interests: J-P Chen received speaker's fees from GlaxoSmith Kline and Pfizer, Inc; H Chung is Medical Director, Depression andAnxiety Management Team, Pfizer, Inc.

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Open Access

Study Protocol

Positive psychotherapy and cognitive behavioral therapy in anxiety patients – A study protocol for a randomized control trial in an online group setting

Roles Conceptualization, Data curation, Funding acquisition, Methodology, Project administration, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Department of Psychology, Paris Lodron University of Salzburg, Salzburg, Austria

Roles Data curation, Writing – original draft, Writing – review & editing

Roles Conceptualization, Funding acquisition, Methodology, Project administration, Supervision

• Catiana L. Engelhardt, 
• Marina Meier, 
• Sabrina Keller, 
• Anton-Rupert Laireiter

• Published: April 16, 2024
• https://doi.org/10.1371/journal.pone.0299803
• Reader Comments

Anxiety disorders are common and debilitating which is why treatment is so important. According to the guidelines, Cognitive Behavioral Therapy (CBT) has the highest level of effectiveness among psychotherapeutic treatments and is the recommended procedure. However, not everyone responds well or at all to CBT which makes a wider range of therapy options valuable. Positive Psychotherapy (PPT) comes to mind as an alternative with its strength-based approach focusing on enhancing well-being and life satisfaction. Additionally, it has not yet been extensively studied how the processes that occur during treatment sessions and between treatment sessions effect treatment outcome. Thus, to lessen the lack of evidence regarding the efficacy of PPT as an anxiety treatment the planned study examines and compares the effectiveness of CBT and PPT as well as the effect of intrasession and intersession processes of the two therapy approaches.

The study is in the planning stage and consists of an efficacy and a process study. The efficacy study is a randomized controlled comparative study of patients with anxiety disorders (generalized anxiety disorder and/or panic disorder with or without agoraphobia) with two active treatment conditions (PPT and CBT) and a control group (CG; positive psychotherapy with minimal therapeutic supervision) in an online group setting. There are three measurement time points: before treatment begins (T0), at the end of the ten-week treatment (T1), and a follow-up after three months (T2). The aim of the study is to evaluate the efficacy of PPT and CBT in the treatment of anxiety disorders, and to compare the efficacy of online-based PPT with minimal therapeutic supervision and online-based PPT with intensive therapeutic supervision in the treatment of anxiety disorders. The process study will be used to evaluate both the intrasession processes and the intersession processes of the therapy in the two intervention groups. In addition, the process variables that predict the success of the therapy and the extent to which PPT and CBT differ in the therapy processes will be tested. The study is registered at the German Clinical Trial Register (№ DRKS00027521).

To our knowledge, this is the first randomized controlled comparative study to examine the effectiveness of CBT and PPT for anxiety disorders in an online group setting.

Citation: Engelhardt CL, Meier M, Keller S, Laireiter A-R (2024) Positive psychotherapy and cognitive behavioral therapy in anxiety patients – A study protocol for a randomized control trial in an online group setting. PLoS ONE 19(4): e0299803. https://doi.org/10.1371/journal.pone.0299803

Editor: Maria José Nogueira, School of Nursing Sao Joao de Deus, Evora University, PORTUGAL

Received: June 21, 2023; Accepted: January 16, 2024; Published: April 16, 2024

Copyright: © 2024 Engelhardt et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: No datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion.

Funding: The University of Salzburg provided support in the form of study assistant salaries to SK and MM. The University of Salzburg is also partially covering the cost of article fees.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Anxiety disorders—epidemiology and treatment approaches.

Anxiety disorders are more widespread and represent one of the most common mental disorders [ 1 , 2 ]. According to international studies, the lifetime prevalence ranges between 14% and 29% [ 2 , 3 ], whereby the quality of life of those affected is often severely restricted. With regard to the so-called “Years Lived with Disability” (YLD), i.e. the years of life lived with disability, according to the World Health Organization (WHO) in 2015 anxiety disorders are in sixth place worldwide. They are thus primarily chronic diseases [ 4 ]. Anxiety disorders are associated with a high utilization of the health care system [ 5 ] and extremely comorbid with other mental illnesses [ 6 , 7 ], such as depression and alcohol dependence [ 8 ]. According to the S3 guidelines for the treatment of anxiety disorders, psychotherapy and pharmacotherapy ought to be offered equally. After giving thorough information about the various treatment options, the patient’s preference should be considered. For all anxiety disorders, CBT has the highest level of evidence and recommendation of all psychotherapeutic methods. In the case of insufficient effectiveness of one form of therapy, the other or a combination of both should be offered [ 5 , 9 ]. Psychodynamic psychotherapy has been included in the current S3 guidelines, with the recommendation that this form of psychotherapy be offered when CBT has proved ineffective, is not available or when there is a preference for it on the part of the informed patient [ 5 ].

Positive psychotherapy

PPT is a science-based psychotherapy that enhances positive emotions, character strengths, and meaning-making in a direct way, with the goal of reversing psychopathologies and promoting the experience of happiness [ 10 ]. In contrast to traditional deficit-oriented treatment models, PPT strives to focus on human well-being and satisfaction. The central assumption is that the evocation and promotion of positive emotions, the awareness of one’s own strengths and the sense of meaning are particularly efficient in the treatment of mental disorders, as people are subject to the so-called negativity bias, especially in stressful life situations. This negativity bias describes the phenomenon that negative thoughts, feelings and experiences have a greater psychological impact than neutral or positive ones [ 11 ]. PPT strives to compensate for this bias by focusing attention on positive things. According to [ 12 ], a lack of positive emotions and well-being can not only be a symptom but also a cause of mental disorders.

Previous efficacy studies on positive psychotherapy

Before PPT was evaluated as an integrated treatment concept, individual interventions were empirically validated [ 13 ]. Individual Positive Psychology interventions have been shown to improve psychological well-being, promote hope and enjoyment, advance psychological rehabilitation and self-esteem, and positively influence psychopathological symptoms [ 13 , 14 ]. In a meta-analysis of the effectiveness of positive psychology interventions, [ 15 ] found small to moderate effects on well-being, strengths, quality of life, depression, anxiety, and stress. Numerous studies regarding the effectiveness of positive-psychological interventions conducted on the disorder depression demonstrated a significant reduction in symptoms and an increase in well-being [ 13 ]. [ 14 ] found that individual PPT with severely depressed patients resulted in symptom improvement and longer remissions compared to usual care including medication therapy. Several studies have demonstrated moderate to strong effects in moderate to severe disorder severity, as well as remission rates of up to one year compared to waiting list control groups or patients treated with antidepressants and psychiatric monitoring [ 12 , 16 – 18 ]. For depression disorder PPT is also highly effective when compared to CBT, as shown in the randomized-controlled comparative study by [ 19 ]. Their results revealed large effects for the reduction of depressive symptomatology, while only small to medium effect sizes were found for CBT. PPT was also superior to CBT in terms of positive outcomes such as life satisfaction and subjective well-being. Additionally, PPT lead to significant effects in the treatment of borderline patients [ 20 ] as well as in the treatment of nicotine dependence [ 21 ]. In summary, based on the studies conducted to date, it can be assumed that PPT is an effective method for several different psychological disorders.

Positive psychotherapy for anxiety disorders

Empirical studies on the effectiveness of PPT for anxiety disorders are rare. In studies on the effectiveness of Well-Being Therapy (WBT) by [ 22 ], which combines both co-behavioural methods and those of Positive Psychology, significant results were achieved. In a controlled comparative study, CBT was compared with WBT in patients with Generalized Anxiety Disorder in a group setting. The study was able to confirm the superiority of WBT both after the end of therapy and in the follow-up examination after one year [ 23 ]. However, due to the small sample size ( N = 9), the significance of this study must be considered low. Another study by Goodwin [Unpublished] was able to show a reduction in anxiety after a ten-week intervention in the form of a PPT treatment. [ 24 ] used a clinical sample ( N = 29) to examine the efficacy of combined PPI intervention on anxiety symptomatology over a treatment period of ten weeks. The study resulted in participants having significantly lower anxiety symptoms and a significantly higher well-being in the pre-post comparison in the intervention group compared to those in the waiting list control group. These effects were still observed in the follow-up (6 months). Like the PPT according to [ 10 ], the intervention by [ 24 ] was conducted in a manualized manner and strongly resembles the PPT manual in terms of the structure of the units and contains comparable interventions.

Intrasession and intersession processes

According to [ 25 , 26 ], the process research phase in psychotherapy represents the fourth and current phase of psychotherapy research. It was preceded by the legitimation phase, the competition phase and the prescription phase. Process research is concerned with investigating the mechanisms of action of psychotherapeutic treatments. Intrasession processes refer to all those changes that occur directly in response to specific events in the therapy session. Whereas intersession processes are defined as conscious processes of change between two sessions that are brought about by representations of the session [ 27 ]. [ 28 ] showed that approximately 90% of all patients engage with therapy or their therapist between sessions. Patients who are more intensely involved in the therapeutic process also show more intense representations [ 29 , 30 ] and a better therapy outcome [ 31 ]. It has also been shown that patients’ positive perceptions of therapy progress are associated with greater involvement in intersession process thoughts and actions [ 32 ]. A clear correlation between positive representations and a good therapeutic relationship has been found [ 33 – 36 ].

Effectiveness of video-assisted therapy

The importance of virtual care has grown strongly especially due to the Covid-19-Pandemic. Additionally, video-assisted therapy is becoming increasingly important and has been used more frequently. In a large-scale meta-analysis, online interventions from 108 randomized controlled trials for 25 different clinical impairments were examined from the period 2000 to 2012 [ 37 ]. Consequently, the effectiveness of online therapy for depression, social phobia, and panic disorders can be considered empirically proven. Further studies are available for eating disorders [ 38 ], pathological gambling [ 39 ], complicated grief [ 40 ], substance-related addictions [ 41 ] and post-traumatic stress disorders [ 42 ], anxiety [ 43 ] and functional disorders [ 37 ], among others. The results of internet-based interventions are promising. For depression, reported effect sizes from five meta-analyses range from d = 0.41 to d = 0.94 [ 44 ], and online programs for anxiety disorders have an average symptom reduction of d = 0.92 [ 45 ]. These results show that online treatments lead to the same neuronal changes as those observed after successful classical psychotherapy [ 46 ]. Another meta-analysis on the effectiveness of online psychotherapy, which included 92 studies with a total of 9764 participants, showed that the mean treatment effect (Cohen’s d ) between pre- and postmeasurement was 0.53, averaged across all disorders and forms of intervention. This effect size is quite comparable to that of conventional outpatient therapy [ 47 ]. [ 48 ] found that both video-based therapy and traditional therapy achieved particularly good effects. Therapeutic success with video-assisted therapy is strongest when using the CBT treatment modality and for anxiety, depression, and Post-Traumatic Stress Disorder. [ 49 ] conducted a study of adolescents with anxiety disorders. While one group received a face-to-face intervention, the other group received video-assisted therapy with less therapeutic support. Both groups showed a significant decrease in anxiety symptomatology, even when compared to a waitlist control group. These effects persisted over time (12-month follow-up). Computer-assisted CBT for anxiety showed similar clinical outcomes to face-to-face psychotherapy [ 50 , 51 ].

Hypotheses and research questions

The main research question of the efficacy study is: Does treatment with PPT and CBT lead to a) a reduction in anxiety symptomatology and to a b) an improvement in general life satisfaction and to c) the promotion of happiness compared to treatment with PPT with minimal therapeutic support after completion of treatment (T1) as well as three months after the treatment has ended (T2). Previous data suggest that Positive Psychology also has exceptionally good effects on anxiety disorders (Goodwin [Unpublished], [ 24 ]). Another important question concerns the evaluation of the intrasession processes and the intersession processes of the two intervention groups. The aim is to examine which process variables predict the success of therapy and whether there are differences between the forms of therapy.

Design and setting

The planned study is a randomized-controlled comparative study and will be realized as a ten-week online group therapy with the following three treatment conditions to which participants will be randomly assigned: Group 1: An intervention condition in which participants receive PPT treatment, Group 2: an intervention condition in which they receive CBT treatment, and Group 3: a control condition designed as PPT treatment with minimal therapeutic supervision. Participants in the control condition receive the same material, content, and exercises as the participants in PPT treatment condition. However, they only have three online video call meetings and work through the content on their own during the remaining weeks. There are three measurement time points for testing the efficacy hypotheses: An online questionnaire survey before treatment begins (PRE measure), a second identical survey after treatment will be completed (POST measure), and a third identical survey three months after treatment will be ended (FOLLOW-UP measure). This results in a 3×3 between- and within-subjects design. The hypotheses regarding the intra- and intersession processes will be tested by means of weekly surveys in each case before the therapy sessions (intersession processes) as well as after the therapy sessions (intrasession processes). Fig 1 shows the study design and the different steps of the procedure in a chronic flow diagram. The study is conducted at the Department of Clinical Psychology and Psychotherapy at the University of Salzburg. Prior to initiation, the study design was submitted to and approved by the Ethics Committee of the University of Salzburg (EK-GZ: 22/2021). The study is registered at the German Clinical Trial Register (№ DRKS00027521; date of registration February, 3 rd 2022; type of registration: prospective). The full details according to the World Health Organization Trial Registration Data Set standards are shown in Table 1 . For a complete description of the relevant information and their position in the manuscript according to the SPIRIT checklist, please refer to S1 Checklist .

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

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Feasibility

The feasibility of the study design was examined as part of a master’s thesis by one of the study assistants. For this purpose, the first study round was evaluated for the effectiveness and feasibility of the interventions, as well as the satisfaction with the therapy from the perspective of the participants and therapists. The results of the work showed high feasibility of the study design, high satisfaction with the therapy, and trends indicating effectiveness of the treatment for anxiety disorders. The detailed results of the feasibility study can be found in the master’s thesis of [ 52 ].

Participants

This trial will include patients who meet the following criteria. Inclusion criteria:

• age between 18 and 65 years
• sufficient intellectual capacity and knowledge of the German language
• F41.0 panic disorder with and without agoraphobia and/or
• F41.1 generalized anxiety disorder and/or
• F40.1 social phobia

Exclusion criteria:

• concurrent or planned participation in psychotherapeutic or psychological treatment or counseling or participation in other psychological group services in the following three months
• presence of one or more of the following disorders: major depressive episode, bipolar affective disorder or mania (current as well as history), schizophrenic or schizoaffective disorder, grief reaction, severe anorexia or bulimia, substance dependence (alcohol, illicit drugs), severe Personality Disorder
• acute suicidality
• use of psychotropic drugs itself not a criterion for exclusion, but a change in medication, a change in dose, or complete discontinuation of the drug in the past or next three months

Sample size

The sample size was calculated using a power analysis (G*Power 3.1; [ 53 ]), given an alpha error of.05 and a power ≥.80, resulting in a sample size of N = 165. Accordingly, 55 persons would be included in each of the three intervention groups. Effect size estimates resulted from findings of previous studies [ 12 , 19 ]. Since a high dropout rate is to be expected, a significantly higher number of subjects will be screened and admitted to the study.

Participant recruitment process

Recruitment will be conducted using a variety of strategies. Part of the recruitment will be done by distributing flyers in pharmacies, doctors’ and psychotherapists’ offices, and other public buildings such as universities, churches, supermarkets, and schools. In addition, clinics, physicians, and psychotherapists will be contacted directly by mail and asked to make patients aware of our offer. At the same time, the study will be advertised online via various social media channels. On the one hand, Facebook is used to post in disorder-specific groups and make those who are affected aware of our offer directly. Instagram is the second platform we will use to promote the study. To do this, an Instagram page will be created for the study. Through this page, various influencers related to the study topic will be contacted via direct message and asked to use their reach and share the study. In addition, own topic-related posts will be created and shared, and advertisements will be placed for the posts. Interested people can contact us via mail to the study mail address, which was communicated via the various advertising tools. To check the general suitability for the study and to filter out suitable participants, interested people will undergo a pre-screening form, which was carried out in the form of an online questionnaire. Based on the evaluation of the pre-screening questionnaire and previously determined cut-off values, a screening appointment will be arranged with suitable applicants. Unsuitable applicants will receive a rejection by e-mail which includes contact details for psychotherapeutic support services. The screening will take place via an online video call using the provider Zoom. It will be conducted by psychologists and master psychology students employed within the study project. In the screening, the German version of the short form of the Diagnostic Interview in Psychological Disorders (MINI-DIPS; [ 54 ]) and the German version of the Personality Disorder Screening—Short Form (PSS-K; [ 55 ]) will be used to check inclusion as well as exclusion criteria and to formulate a diagnosis. In addition, information about the procedures and contents of the study and the various data collection procedures will be given, and informed consent will be obtained from the participants to participate in the study and to complete the mandatory evaluation questionnaires. All participants will be also given the telephone number of the crisis service responsible for their area so that they can contact them in the event of an emergency.

Randomization and blinding

With the help of the online platform randomizer.org participants will be randomly allocated to three test conditions right after they completed the PRE-evaluation form. The allocation is random and independent of the diagnosis or other criteria. The externally recruited therapists will be blindly assigned to the treatment conditions. Neither the participants nor the practitioners were allowed to decide which group they were assigned to. The authors, who also act as therapists, will conduct the control group to prevent falsification effects in the intervention groups. Statistical analyses will be conducted by the principal investigator, who will not be blinded or independent.

Interventions

The first step in conducting the study was the development of the treatment manuals and therapy materials. Two treatment manuals were developed, one each for PPT and CBT treatment. The PPT manual is based on the official PPT manual by [ 10 ] and adapted for the study. Because of economic reasons instead of 15 sessions as in the original manual, only 10 therapy sessions are conducted in the present study. In addition, the individual PPT topics were adapted and exercises from the personal PPT application repertoire of the study leaders were incorporated. As in the original manual, a gratitude diary will be filled out daily by the participants accompanying the therapy. In the individual sessions, various positive-psychological interventions are carried out, e.g., participants learn how to handle and use positive emotions, work out their personal character strengths and learn how to use them in concrete anxiety situations. Other topics covered in the PPT treatment include gratitude, optimism, a positive self-image, self-compassion, resilience, everest goals, best-possible self, and future perspective. The CBT manual is conceptually adapted to the PPT treatment and also comprises 10 therapy sessions. The exercises and content were selected based on the German language therapy tools for anxiety disorders by [ 56 ]. In the CBT treatment, participants are required to practice the relaxation exercise Progressive Muscle Relaxation according to Jacobsen on a daily basis. In CBT treatment, participants learn how to deal with anxiety thoughts and behavior and how to restructure stressful anxiety related cognitions. For this purpose, various cognitive-behavioral therapy interventions are carried out, e.g., the development of an individual explanatory model, the worry chair and various attention and breathing exercises. An elementary part of the treatment is an exposure exercise, which is worked towards during therapy. Other topics covered in CBT treatment include the three levels of anxiety (body, thoughts, behavior), the vicious cycle of anxiety, and mindfulness. In addition to the treatment manuals, workbooks were created for the participants to work on during the therapy. The workbooks contain all organizational details, theoretical topics as well as all exercises and worksheets that must be done in the video-supported sessions or as homework. Additional websites (created by Webflow) were provided for both intervention groups to make additional therapy tools available, such as videos or questionnaires. That aside the websites are also used to conduct part of the data collection. The implementation of the treatments takes place online via videoconferencing using the Zoom platform. Participants in the two intervention conditions (PPT & CBT) will meet once a week with the treatment providers for a 120-minute online presence meeting, in which the content of the respective sessions will be conducted according to the manual. In addition, participants will be given homework assignments to complete independently for the week between the face-to-face sessions. These homework assignments will be discussed in the group at the beginning of each session. The control group is designed as a PPT with minimal therapeutic supervision. The participants will receive the same PPT workbook as the intervention group and accordingly will work on the same topics and exercises over the ten weeks as the participants in the PPT intervention group. The difference between the two groups lies in the therapeutic support. In the control group, a video-supported meeting with the therapist will be held only three times: In the first session, halfway through therapy in the fifth session, and in the last session. In between, participants receive an overview email at the beginning of the week and a reminder email at the end of the week. Apart from the possibility of mail contact with the therapists, the participants in the control group carry out the exercises independently with the help of the workbook and the materials on the website. For the control group, as for the intervention groups, a separate website is provided. Another important component of all treatment conditions is the formation of teams of two clients (couple teams) within each therapy group. These teams will be formed in the first session of therapy and will remain in place throughout the duration of therapy. Participants are encouraged to meet at least once a week to discuss the week’s exercises and topics with each other. In some cases, specific reflection questions will be provided in the individual exercises in the workbook. Depending on the possibilities of the participants, the meeting could take place online via a telephone call or video call or in person. When forming the couple teams, deliberate care was taken to divide the participants according to local proximity.

Outcome measures

Proposed psychological outcome measures are as follows. All named questionnaires are based on self-report.

Primary outcome measures.

• Beck Anxiety Inventory German version (BAI; [ 57 ])
• Panic and Agoraphobia Scale German version (PAS; [ 58 ])
• Generalized Anxiety Disorder 7 German version (GAD-7; [ 59 ])
• Fear Questionnaire German version (FQ; [ 60 ])
• Positive Psychotherapy Inventory German version (PPTI; [ 10 ])
• Flourishing Scale German version (FS; [ 61 ])
• Satisfaction with Life Scale German version (SWLS; [ 62 ])

For additional third-party assessment of the level of anxiety a questionnaire designed by the authors was used (the following topics were queried: tension, anxious mood, fear, sleep disturbance, depressiveness, anxious behavior, physical symptomatology, psychological distress, impairment in living, life satisfaction, motivation & energy).

Secondary outcome measures.

• ICD-10 symptom rating German version (ISR [ 63 ])
• Patient Health Questionnaire German version (PHQ 9 [ 64 ])

For the evaluation of intra- & intersession processes intra-session processes will be assessed using the Patient Session-Assessment Questionnaire German version (STU-P, ger. orig.: “Stunden Beurteilungsbogen für Patienten”; [ 65 ]) and intersession processes will be assessed using the Intersession-Questionnaire German version (ISF, ger. orig.: “Intersession Fragebogen”; [ 66 ]).

Data collection

All self-report measures will be collected by computerized questionnaires, using different online survey platforms. For T0, T1 & T2 evaluation (see Fig 2 ), Google forms will be used. For evaluating intra- and intersession processes forms included at our study websites will be used. Table 2 shows an overview of all measurement instruments used across the different measurement time points of the study. Access to any data is restricted to trial personnel and investigators. Name, e-mail address and telephone number are required for organizational purposes and for sending the links for the online data collection. These data are recorded independently of the other study-related data only by the study director in an Excel spreadsheet and kept in a password-protected laptop. Nobody else has access to it. All other data will be collected pseudonymously via a subject code to be generated by the patients themselves (= individual code). Anonymity is to be protected on different levels. At the level of the practitioner, it is protected by the professional laws. The practitioners are bound to secrecy according to the Austrian Psychologists’ Act and the German Psychotherapists’ Act. Accordingly, no information about the persons and their treatment may be disclosed to the outside. Only during supervision and intervision may the contents of the units be discussed anonymously. However, the supervisors are also subject to the same professional laws as the therapists, so that the data of the subjects are also protected at this level. At the level of research data, the pseudonymization by means of individual codes makes it impossible to assign the data to any specific person, unless the person discloses his or her individual code. At the level of the actual personal data, anonymity is ensured by the fact that only the study director has access to this data and only is aware of it. However, even he or she cannot establish an assignment of the names to the data because he or she does not have the individual codes. The personal data are accessible only through a password-protected table in an equally protected laptop.

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Statistical analysis

The primary outcome is pre-post and follow-up change in anxiety and positive outcomes (overall life satisfaction, happiness experience). In this study, we will conduct an intention-to-treat analysis. For the statistical analysis of the primary outcome, we will conduct a repeated measures ANOVA with three independent variables (PPT, CBT, CG). For the process study, two ANOVAs will be conducted with two independent variables each (emotional experience positive/negative and level of session activity high/low).

Trial governance

The Trial Management Group consists of the principal investigator, the study director (A.- R. Laireiter) and is supported by two study assistants. The Management Group will provide overall management of the study including set-up of the study, recruitment, managing mails, and interpretation of results. In addition, eleven therapists (psychological psychotherapists in training) support the study by conducting the therapy groups. In preparation for the study, therapy manuals, websites and workbooks were developed for the different intervention groups by the principal investigator, the study director and a study assistant. Overall supervision of the trial is provided by the principal investigator. The therapists were trained in the manuals and for screenings by the project management. All therapists were trained in both manuals in order to be able to adopt both intervention groups (PPT and CBT) as needed during the course of the various study runs. At regular intervals, the therapy sessions are checked for their manual compliance and the therapists receive supervision by qualified psychotherapists and supervisors.

This study investigates the efficacy of Positive Psychotherapy and Cognitive Behavioral Therapy in patients with anxiety disorders in an online-based group setting. Conventional treatments for anxiety disorders focus primarily on cognitive strategies and relaxation techniques, as well as exposure [ 5 ]. The treatment focus of Positive Psychotherapy is on positive affect and enhancing general well-being. So far, research focused on the efficacy of (online-based) CBT as a treatment for anxiety and is referred to as the gold standard for treating a wide range of disorders. Current studies show that Positive Psychology Interventions prove to be effective for depression and psychological well-being [ 16 , 67 ] as well as anxiety [ 68 , 69 ]. However, until now no study concentrated on comparing the efficacy of both treatments (CBT & PPT) in people struggling with anxiety disorders in an online-based group setting. Thus, no concrete evidence has been found which supports using PPT to treat anxiety disorders or other mental disorders. Positive Psychotherapy may be a much-needed alternative for people not responding well to CBT and the online-group setting makes the therapy more accessible to people with restricted mobility or severe symptoms. Since people with anxiety often lead lives in which they avoid situations or places that trigger their fears and become more withdrawn as a result, online interventions could facilitate entry into therapy. Another potential strength is that online (group) therapy can be considered a cost-effective setting [ 70 , 71 ]. Times like the coronavirus pandemic, where therapy sessions had to be postponed or other ways to continue had to be figured out, display the usefulness of online therapy. Additionally, it is unclear which process variables predict therapy success. The impact of intersession and intrasession processes for therapy success has not been extensively studied. However, recent studies suggest a positive correlation between these processes and a positive therapy result [ 32 , 72 ]. In this study we want to explore whether intrasession and/or intersession processes contribute to the effectiveness of the treatment and if so, whether a difference can be observed depending on the treatment (CBT or PPT). In the present study, a pure waiting list control group design is deliberately not used, since this allows statements on the absolute effectiveness of a treatment, but is weak in terms of the effectiveness of treatments in comparison to already established and comparable approaches. In addition, wait-list control groups are widely used in research, whereas comparisons with active alternative treatments are less common.

Limitations

Due to the online design of this study, it is more difficult to motivate and regulate the subjects’ participation. Therefore, we heavily relied on the intrinsic motivation (in addition to the overall satisfaction rate regarding the treatment) and commitment of the participants, which was met with considerably great interindividual variability. Since only individuals from mainly Germany and Austria were recruited, general statements about the results of our study can only be drawn for the western population. For future research, a more global-based study should be considered. Nonetheless, we expect that our study reveals valuable results that further research regarding online-based group therapy and contribute to a better understanding of the possible variables affecting therapy success. If proven that positive psychotherapy is beneficial or even as effective as cognitive behavioral therapy in patients with anxiety disorders, this could provide an alternative to conventional therapy approaches.

Supporting information

S1 checklist. spirit checklist..

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Generalized Anxiety Disorder

• Diagnosis |
• Treatment |
• More Information |

Generalized anxiety disorder consists of excessive nervousness and worry about a number of activities or events. People have anxiety more days than not over a period of 6 months or longer. The cause is unknown, although it commonly coexists in people who have alcohol use disorder , major depression , or panic disorder .

People are anxious and worried about a variety of issues, activities, and situations, not just one type.

For this disorder to be diagnosed, several other symptoms (such as a tendency to tire easily, difficulty concentrating, and muscle tension) must accompany the anxiety.

Treatment involves a combination of medications (usually antianxiety medications and sometimes antidepressants) and psychotherapy.

Generalized anxiety disorder is a common type of anxiety disorder . About 3% of adults have it yearly. Women are twice as likely as men to have the disorder. The disorder more commonly begins in adulthood but may start at any age (see Generalized Anxiety Disorder in Children ).

For most people, the disorder fluctuates, worsening at times (especially during times of stress), and persists over many years.

Symptoms of Generalized Anxiety Disorder

People with generalized anxiety disorder constantly feel worried or distressed and have difficulty controlling these feelings. The severity, frequency, or duration of the worries is greater than the situation warrants.

Worries are general in nature, include many topics, and often shift from one topic to another over time. Common worries include work and family responsibilities, money, health, safety, car repairs, and chores.

Diagnosis of Generalized Anxiety Disorder

A doctor's evaluation, based on standard psychiatric diagnostic criteria

For a doctor to diagnose generalized anxiety disorder, a person must experience worry or anxiety that

Is excessive

Concerns a number of activities and events

Is present more days than not over a period of 6 months or longer

In addition, the person must have 3 or more of the following symptoms:

Restlessness or a keyed-up or on-edge feeling

A tendency to tire easily

Difficulty concentrating

Irritability

Muscle tension

Disturbed sleep

Before diagnosing generalized anxiety disorder, doctors do a physical examination. They may do blood or other tests to make sure the symptoms are not caused by a physical disorder or use of a drug.

Treatment of Generalized Anxiety Disorder

A combination of psychotherapy and medications

The disorder is often managed with a combination of some form of psychotherapy and drug therapy. Psychotherapy can address the causes of anxiety and provide ways to cope.

Some antidepressants norepinephrine Antianxiety and Sedative Drugs ), these medications are usually given for only a relatively short time. Once the antidepressant and psychotherapy becomes effective, the dose of the benzodiazepine may be decreased slowly, then stopped. Benzodiazepines should not be stopped abruptly.

Herbal products such as kava and may have antianxiety effects, although their effectiveness and safety for treating anxiety disorders such as generalized anxiety disorder require further study.

Cognitive-behavioral therapy has been shown to be beneficial for generalized anxiety disorder. With this therapy, people learn to do the following:

Recognize where their thinking is distorted

Control their distorted thinking

Modify their behavior accordingly

Relaxation, yoga, meditation, exercise, and biofeedback techniques may also be of some help (see Mind-Body Techniques ).

More Information

The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

National Institute of Mental Health, Generalized Anxiety Disorder : Basic information on many aspects of generalized anxiety disorder, including prevalence statistics

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Generalized Anxiety Disorder & Panic Anxiety

Aug 01, 2014

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Lam#27, Linh#28 Per.6. Generalized Anxiety Disorder & Panic Anxiety. Case Study.

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Lam#27, Linh#28 Per.6 Generalized Anxiety Disorder&Panic Anxiety

Case Study • Homer, who is eating a snack calmly, gets an unexpected wave of panic, out of nowhere. His heart raced, and became sweaty, worrying he may die. To make matters worse, he finds himself with nowhere to escape very easily

Definitions • Generalized Anxiety Disorder (GAD)-psychological problem characterized by persistent feelings of anxiety without external cause. Symptoms: -constant worry over nothing -no relaxation -jumpy -nausea • Panic Disorder: sudden urge of overwhelming anxiety and fear; unlike GAD victim is usually free of anxiety between panic attacks. Symptoms: -nausea -uncontrollable breathing and heart rate

Theories of These Disorders • Biological Perspective: -There’s imbalance of seretonin (mood), norepinephrine (sleep), and GABA (relaxing) • Psychodynamic Perspective: -This includes the unconscious mental life and defense mechanisms until alertness • Cognitive-Behavioral Perspective: -Theorists viewed panic attacks as conditioned response to learned physical sensations • Humanistic Perspective: -People with panic disorders or GAD may not be meeting their safety need of their goals

Treatments of GAD For GAD: -Use the method of this acronym: AWARE Acceptance (welcome it, don’t fight it) Watch (look at your anxiety w/o judgments; separate yourself from it) Act with it (breathe slowly and normally; allow anxiety to leave your mind) Repeat (continue the three steps) Expect the best (know your potential anxiety for your future)

The Drug Route • Benzodiazephines • Barbituates • Valium

Facts Victims of panic disorder have addition symptoms of agoraphobia (open space) Agoraphobia affects 35%-37% of population a year with GAD You can get accustomed to anxiety that you won’t even feel it anymore but your body still shows signs of anxiety Animals also have anxiety

Sources That darn psych book….. Helpguide.org/mental/generalized_anxiety_disorder.htm Webmd.com/facts_of_panic_disorder.htm wikipedia.org/disorders.htm

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