Hostname: page-component-8448b6f56d-sxzjt Total loading time: 0 Render date: 2024-04-19T18:43:33.666Z Has data issue: false hasContentIssue false
  • English
  • Français

Cognitive Behavior Therapy Targeting Intolerance of Uncertainty Versus Selective Serotonin Reuptake Inhibitor for Generalized Anxiety Disorder: A Randomized Clinical Trial

Published online by Cambridge University Press:  01 September 2021

Mehdi Zemestani Open the ORCID record for Mehdi Zemestani [Opens in a new window] ,
Negar Beheshti ,
Farzin Rezaei ,
Colin van der Heiden  and
Philip C. Kendall
Mehdi Zemestani*
Affiliation:
Department of Clinical Psychology, University of Kurdistan, Sanandaj, Iran
Negar Beheshti
Affiliation:
Department of Clinical Psychology, University of Kurdistan, Sanandaj, Iran
Farzin Rezaei
Affiliation:
Department of Psychiatry, Kurdistan University of Medical Sciences, Sanandaj, Iran Neuroscience Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
Colin van der Heiden
Affiliation:
Outpatient Treatment Centre PsyQ & Erasmus University, Rotterdam, Netherlands
Philip C. Kendall
Affiliation:
Department of Psychology, Temple University, Philadelphia, Pennsylvania, USA
*
*Corresponding author: Mehdi Zemestani, Department of Clinical Psychology, University of Kurdistan, Sanandaj, Iran. Email: m.zemestani@uok.ac.ir
Get access

Abstract

Given the high prevalence and adverse outcomes associated with generalized anxiety disorder (GAD), development and expansion of effective treatment modalities are important. The present study compared the effectiveness of cognitive behavior therapy targeting intolerance of uncertainty (CBT-IU) and selective serotonin reuptake inhibitors (SSRIs) for treating GAD. A total of 30 Iranian patients with GAD (Mage = 25.16 ± 6.73) were randomised to receive either CBT-IU (n = 15) or SSRI (n = 15). Measures included the Structured Clinical Interview for DSM-5 (SCID-5), Penn State Worry Questionnaire (PSWQ), Why Worry-II (WW-II), Intolerance of Uncertainty Scale (IUS), and Negative Problem Orientation Questionnaire (NPOQ). Repeated measures analysis of variance tested differential treatment outcomes. The results of intention-to-treat (ITT) analysis indicated that although both CBT-IU and SSRI were effective treatments for GAD, CBT-IU produced significantly better results than SSRI at post-treatment. This clinical trial provides preliminary cross-cultural support for the treatment of GAD using CBT-IU, with findings suggesting that this non-medication intervention reduces GAD symptoms.

Keywords

CBTgeneralized anxiety disorderintolerance of uncertaintypharmacotherapyselective serotonin reuptake inhibitors
Type
Standard Paper
Information
Behaviour Change , Volume 38 , Issue 4 , December 2021 , pp. 250 - 262
Copyright
Copyright © The Author(s), 2021. Published by Cambridge University Press on behalf of the Australian Association for Cognitive and Behaviour Therapy

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Alloy, LB, Abramson, LY, Whitehouse, WG, Hogan, ME, Panzarella, C and Rose, DT (2006). Prospective incidence of first onsets and recurrences of depression in individuals at high and low cognitive risk for depression. Journal of Abnormal Psychology, 115, 145–156.CrossRefGoogle ScholarPubMed
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). Washington, DC: American Psychiatric Pub.Google Scholar
Baldwin, DS, Hou, R, Gordon, R, Huneke, N and Garner, M (2017). GAD: Experimental medicine models, emerging targets: Pharmacotherapy in generalized anxiety disorder: Novel experimental medicine models and emerging drug targets. CNS Drugs 31, 307–317.CrossRefGoogle ScholarPubMed
Beck, AT (1976). Cognitive therapy and the emotional disorders. New York, NY: International Universities Press.Google Scholar
Bolognesi, F, Baldwin, D and Ruini, C (2014). Psychological interventions in the treatment of generalized anxiety disorder: A structured review. Journal of Psychopathology, 20, 111–126.Google Scholar
Bomyea, J, Ramsawh, H, Ball, T, Taylor, C, Paulus, M, Lang, A and Stein, M (2015). Intolerance of uncertainty as a mediator of reductions in worry in a cognitive behavioral treatment program for generalized anxiety disorder. Journal of Anxiety Disorders, 33, 90–94.CrossRefGoogle Scholar
Borkovec, T, Newman, MG, Pincus, AL and Lytle, R (2002). A component analysis of cognitive-behavioral therapy for generalized anxiety disorder and the role of interpersonal problems. Journal of Consulting and Clinical Psychology, 70, 288–298.CrossRefGoogle ScholarPubMed
Carl, E, Witcraft, SM, Kauffman, BY, Gillespie, EM, Becker, ES, Cuijpers, P, … Powers, MB (2020). Psychological and pharmacological treatments for generalized anxiety disorder (GAD): A meta-analysis of randomized controlled trials. Cognitive Behaviour Therapy, 49, 1–21.CrossRefGoogle ScholarPubMed
Carleton, RN (2016). Into the unknown: A review and synthesis of contemporary models involving uncertainty. Journal of Anxiety Disorders, 39, 30–43.CrossRefGoogle ScholarPubMed
Chambless, DL and Hollon, SD (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66, 7.CrossRefGoogle ScholarPubMed
Chen, T-R, Huang, H-C, Hsu, J-H, Ouyang, W-C and Lin, K-C (2019). Pharmacological and psychological interventions for generalized anxiety disorder in adults: A network meta-analysis. Journal of Psychiatric Research, 118, 73–83.CrossRefGoogle ScholarPubMed
Clark, DA and Beck, AT (2011). Cognitive therapy of anxiety disorders: Science and practice. New York: Guilford Press.Google Scholar
Covin, R, Ouimet, AJ, Seeds, PM and Dozois, DJA (2008). A meta-analysis of CBT for pathological worry among clients with GAD. Journal of Anxiety Disorders, 22, 108–116. doi:10.1016/j.janxdis.2007.01.002.CrossRefGoogle ScholarPubMed
Cuijpers, P, Cristea, IA, Karyotaki, E, Reijnders, M and Huibers, MJH (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry, 15, 245–258. doi:10.1002/wps.20346.CrossRefGoogle Scholar
Cuijpers, P, Eylem, O, Karyotaki, E, Zhou, X and Sijbrandij, M (2019) Psychotherapy for depression and anxiety in low-and middle-income countries. In Stein, DJ, Bass, JK and Hofmann, SG (eds), Global Mental Health and Psychotherapy. United States: Academic Press, Elsevier, pp. 173–192.CrossRefGoogle Scholar
Dugas, MJ and Ladouceur, R (2000). Treatment of GAD: Targeting intolerance of uncertainty in two types of worry. Behavior Modification, 24, 635–657.CrossRefGoogle Scholar
Dugas, MJ and Robichaud, M (2012). Cognitive-behavioral treatment for generalized anxiety disorder: From science to practice. Routledge.Google Scholar
Dugas, MJ, Gagnon, F, Ladouceur, R and Freeston, MH (1998). Generalized anxiety disorder: A preliminary test of a conceptual model. Behaviour Research and Therapy, 36, 215–226.CrossRefGoogle ScholarPubMed
Dugas, MJ, Ladouceur, R, Léger, E, Freeston, MH, Langolis, F, Provencher, MD and Boisvert, J-M (2003). Group cognitive-behavioral therapy for generalized anxiety disorder: Treatment outcome and long-term follow-up. Journal of Consulting and Clinical Psychology, 71, 821–825.CrossRefGoogle ScholarPubMed
Dugas, MJ, Savard, P, Gaudet, A, Turcotte, J, Laugesen, N, Robichaud, M, … Koerner, N (2007). Can the components of a cognitive model predict the severity of generalized anxiety disorder? Behavior Therapy, 38, 169–178.CrossRefGoogle ScholarPubMed
Dugas, MJ, Brillon, P, Savard, P, Turcotte, J, Gaudet, A, Ladouceur, R, … Gervais, NJ (2010). A randomized clinical trial of cognitive-behavioral therapy and applied relaxation for adults with generalized anxiety disorder. Behavior Therapy, 41, 46–58.CrossRefGoogle ScholarPubMed
Dugas, MJ, Laugesen, N and Bukowski, WM (2012). Intolerance of uncertainty, fear of anxiety, and adolescent worry. Journal of Abnormal Child Psychology, 40, 863–870.CrossRefGoogle ScholarPubMed
First, MB and Williams, JB (2016). SCID-5-CV: Structured clinical interview for DSM-5 disorders: Clinician version. Washington, DC: American Psychiatric Association Publishing.Google Scholar
Freeston, MH, Rhéaume, J, Letarte, H, Dugas, MJ and Ladouceur, R (1994). Why do people worry? Personality and Individual Differences, 17, 791–802.CrossRefGoogle Scholar
Gonçalves, DC and Byrne, GJ (2012). Interventions for generalized anxiety disorder in older adults: Systematic review and meta-analysis. Journal of Anxiety Disorders, 26, 1–11. doi:10.1016/j.janxdis.2011.08.010.CrossRefGoogle ScholarPubMed
Gosselin, P, Ladouceur, R, Langlois, F, Freeston, MH, Dugas, MJ and Bertrand, J (2003). Développement et validation d'un nouvel instrument évaluant les croyances erronéesà l'égard des inquiétudes [Development and validation of a new instrument to evaluate erroneous beliefs about worries]. European Review of Applied Psychology/Revue Européenne de Psychologie Appliquée, 53, 199–211.Google Scholar
Guaiana, G, Barbui, C and Abouhassan, R (2018). Antidepressants versus placebo for generalised anxiety disorder (GAD). Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD012942.CrossRefGoogle Scholar
Hanrahan, F, Field, AP, Jones, FW and Davey, GC (2013). A meta-analysis of cognitive therapy for worry in generalized anxiety disorder. Clinical Psychology Review, 33, 120–132.CrossRefGoogle ScholarPubMed
Hebert, EA and Dugas, MJ (2018). Behavioral experiments for intolerance of uncertainty: Challenging the unknown in the treatment of generalized anxiety disorder. Cognitive and Behavioral Practice, 26, 421–436.CrossRefGoogle Scholar
Hebert, EA, Dugas, MJ, Tulloch, TG and Holowka, DW (2014). Positive beliefs about worry: A psychometric evaluation of the Why Worry-II. Personality and Individual Differences, 56, 3–8.CrossRefGoogle Scholar
Hunot, V, Churchill, R, Teixeira, V and de Lima, MS (2007). Psychological therapies for generalised anxiety disorder. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD001848.pub4.CrossRefGoogle ScholarPubMed
Jacobson, NS and Truax, P (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12.CrossRefGoogle ScholarPubMed
Katzman, MA, Bleau, P, Blier, P, Chokka, P, Kjernisted, K, Van Ameringen, M … University M (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry, 14, S1. doi:10.1186/1471-244x-14-s1-s1.CrossRefGoogle ScholarPubMed
Kessler, CK, Petukhova, M, Sampson, NA, Zaslavsky, AM and Wittchen, H-U (2012). Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods in Psychiatric Research, 21, 169–184. doi:10.1002/mpr.1359.CrossRefGoogle ScholarPubMed
Koerner, N and Dugas, MJ (2006). A cognitive model of generalized anxiety disorder: The role of intolerance of uncertainty. In Graham, GCL and Wells, A (eds), Worry and its psychological disorders: Theory, assessment and treatment. UK: John Willy & Sons, pp. 201–216.CrossRefGoogle Scholar
Ladouceur, R, Dugas, MJ, Freeston, MH, Léger, E, Gagnon, F and Thibodeau, N (2000). Efficacy of a cognitive-behavioral treatment for generalized anxiety disorder: Evaluation in a controlled clinical trial. Journal of Consulting and Clinical Psychology, 68, 957–964. doi:10.1037/0022-006X.68.6.957.CrossRefGoogle Scholar
Llera, SJ and Newman, MG (2014). Rethinking the role of worry in generalized anxiety disorder: Evidence supporting a model of emotional contrast avoidance. Behavior Therapy, 45, 283–299.CrossRefGoogle Scholar
McLean, CP, Asnaani, A, Litz, BT and Hofmann, SG (2011). Gender differences in anxiety disorders: Prevalence, course of illness, comorbidity and burden of illness. Journal of Psychiatric Research, 45, 1027–1035.CrossRefGoogle ScholarPubMed
Mennin, DS, Fresco, DM, O'Toole, MS and Heimberg, RG (2018). A randomized controlled trial of emotion regulation therapy for generalized anxiety disorder with and without co-occurring depression. Journal of Consulting and Clinical Psychology, 86, 268–281. doi:10.1037/ccp0000289.CrossRefGoogle ScholarPubMed
Meyer, TJ, Miller, ML, Metzger, RL and Borkovec, TD (1990). Development and validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 28, 487–495.CrossRefGoogle ScholarPubMed
Mitte, K (2005). Meta-analysis of cognitive-behavioral treatments for generalized anxiety disorder: A comparison with pharmacotherapy. Psychological Bulletin, 131, 785.CrossRefGoogle ScholarPubMed
Molina, S and Borkovec, TD (1994) The Penn State Worry Questionnaire: Psychometric properties and associated characteristics. In Davey, GCL and Tallis, F (eds), Worrying: Perspectives on theory, assessment and treatment. New York: John Wiley & Sons, pp. 265–283.Google Scholar
Otte, C (2011). Cognitive behavioral therapy in anxiety disorders: Current state of the evidence. Dialogues in Clinical Neuroscience, 13, 413–421.Google ScholarPubMed
Ouellet, C, Langlois, F, Provencher, M and Gosselin, P (2019). Intolerance of uncertainty and difficulties in emotion regulation: Proposal for an integrative model of generalized anxiety disorder. Revue Européenne de Psychologie Appliquée, 69, 9–18.CrossRefGoogle Scholar
Perna, G, Alciati, A, Riva, A, Micieli, W and Caldirola, D (2016). Long-term pharmacological treatments of anxiety disorders: An updated systematic review. Current Psychiatry Reports, 18, 23. doi:10.1007/s11920-016-0668-3.CrossRefGoogle Scholar
Renjan, V, McEvoy, PM, Handley, AK and Fursland, A (2016). Stomaching uncertainty: Relationships among intolerance of uncertainty, eating disorder pathology, and comorbid emotional symptoms. Journal of Anxiety Disorders, 41, 88–95.CrossRefGoogle ScholarPubMed
Revicki, DA, Travers, K, Wyrwich, KW, Svedsäter, H, Locklear, J, Mattera, MS, … Montgomery, S (2012). Humanistic and economic burden of generalized anxiety disorder in North America and Europe. Journal of Affective Disorders, 140, 103–112.CrossRefGoogle ScholarPubMed
Robichaud, M (2013). Cognitive behavior therapy targeting intolerance of uncertainty: Application to a clinical case of generalized anxiety disorder. Cognitive and Behavioral Practice, 20, 251–263.CrossRefGoogle Scholar
Robichaud, M and Dugas, MJ (2005) Negative problem orientation (Part I): Psychometric properties of a new measure. Behaviour Research Therapy 43, 391–401.CrossRefGoogle ScholarPubMed
Robichaud, M, Koerner, N and Dugas, MJ (2019). Cognitive behavioral treatment for generalized anxiety disorder: From science to practice. New York: Routledge.CrossRefGoogle Scholar
Roemer, L and Orsillo, SM (2014). An acceptance-based behavioral therapy for generalized anxiety disorder. In Barlow, DH (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (5th ed., pp. 206–237). New York: Guilford Press.Google Scholar
Rosser, BA (2019). Intolerance of uncertainty as a transdiagnostic mechanism of psychological difficulties: A systematic review of evidence pertaining to causality and temporal precedence. Cognitive Therapy and Research, 43, 438–463.CrossRefGoogle Scholar
Ruscio, AM, Hallion, LS, Lim, CC, Aguilar-Gaxiola, S, Al-Hamzawi, A, Alonso, J, … Bunting, B (2017). Cross-sectional comparison of the epidemiology of DSM-5 generalized anxiety disorder across the globe. JAMA Psychiatry, 74, 465–475.CrossRefGoogle ScholarPubMed
Schatzberg, AF and DeBattista, C (2015). Manual of clinical psychopharmacology. Washington, DC: American Psychiatric Pub.CrossRefGoogle Scholar
Shankman, SA, Funkhouser, CJ, Klein, DN, Davila, J, Lerner, D and Hee, D (2018). Reliability and validity of severity dimensions of psychopathology assessed using the Structured Clinical Interview for DSM-5 (SCID). International Journal of Methods in Psychiatric Research, 27, e1590.CrossRefGoogle Scholar
Shihata, S, McEvoy, PM, Mullan, BA and Carleton, RN (2016). Intolerance of uncertainty in emotional disorders: What uncertainties remain? Journal of Anxiety Disorders, 41, 115–124.CrossRefGoogle ScholarPubMed
Slee, A, Nazareth, I, Bondaronek, P, Liu, Y, Cheng, Z and Freemantle, N (2019). Pharmacological treatments for generalised anxiety disorder: A systematic review and network meta-analysis. The Lancet, 393, 768–777.CrossRefGoogle ScholarPubMed
Szkodny, LE, Newman, MG and Goldfried, MR (2014). Clinical experiences in conducting empirically supported treatments for generalized anxiety disorder. Behavior Therapy, 45, 7–20.CrossRefGoogle ScholarPubMed
van der Heiden, C, Muris, P and van der Molen, HT (2012). Randomized controlled trial on the effectiveness of metacognitive therapy and intolerance-of-uncertainty therapy for generalized anxiety disorder. Behaviour Research and Therapy, 50, 100–109. doi:10.1016/j.brat.2011.12.005.CrossRefGoogle ScholarPubMed
Vesga-López, O, Schneier, F, Wang, S, Heimberg, R, Liu, SM, Hasin, DS and Blanco, C (2008). Gender differences in generalized anxiety disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). The Journal of Clinical Psychiatry, 69, 1606–1616.CrossRefGoogle Scholar
Waters, AM and Craske, MG (2005). Generalized anxiety disorder. In Antony, MM, Ledley, DR and Heimberg, RG (eds), Improving outcomes and preventing relapse in cognitive behavioral therapy. New York: Guilford Press, pp. 77–127.Google Scholar
Wells, A (2005). The metacognitive model of GAD: Assessment of meta-worry and relationship with DSM-IV generalized anxiety disorder. Cognitive Therapy and Research, 29, 107–121.CrossRefGoogle Scholar
Wells, A, Welford, M, King, P, Papageorgiou, C, Wisely, J and Mendel, E (2010). A pilot randomized trial of metacognitive therapy vs applied relaxation in the treatment of adults with generalized anxiety disorder. Behaviour Research and Therapy, 48, 429–434.CrossRefGoogle ScholarPubMed
Wittchen, H-U and Jacobi, F (2005). Size and burden of mental disorders in Europe—A critical review and appraisal of 27 studies. European Neuropsychopharmacology, 15, 357–376.CrossRefGoogle ScholarPubMed
Zemestani, M and Fazeli Nikoo, Z (2020) Effectiveness of mindfulness-based cognitive therapy for comorbid depression and anxiety in pregnancy: a randomized controlled trial. Archives of Women's Mental Health 23, 207–214.CrossRefGoogle ScholarPubMed
Zemestani, M, Davoodi, I, Honarmand, MM, Zargar, Y and Ottaviani, C (2016). Comparative effects of group metacognitive therapy versus behavioural activation in moderately depressed students. Journal of Mental Health, 25, 479–485. doi:10.3109/09638237.2015.1057326.CrossRefGoogle ScholarPubMed
Zemestani, M, Salavati, M, Seyedolshohadayi, A, Petersen, JM, Ong, CW, Twohig, MP and Ghaderi, E (2020). A preliminary examination of acceptance and commitment therapy versus exposure and response prevention for patients with obsessive-compulsive disorder on an optimal dose of SSRIs: A randomized controlled trial in Iran. Behavior Modification, 1–28. doi:10.1177/0145445520982977.Google Scholar
Zemestani, M, Ommati, P, Rezaei, F and Gallagher, MW (2021). Changes in neuroticism-related constructs over the unified protocol for transdiagnostic treatment of emotional disorders in patients on an optimal dose of SSRI. Personality Disorders: Theory, Research, and Treatment. doi:10.1037/per0000482.CrossRefGoogle Scholar
Zemestani, M, Didehban, R, Comer, JS and Kendall, PC (2021). Psychometric evaluation of the intolerance of uncertainty scale for children (IUSC): Findings from clinical and community samples in Iran. Assessment. doi:1073191121998769.CrossRefGoogle ScholarPubMed