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Objective-Recent models suggest that generalized anxiety disorder (GAD) symptoms may be maintained by emotional processing avoidance and interpersonal problems.Method-This is the first randomized controlled trial to test directly whether cognitivebehavioral therapy (CBT) could be augmented with the addition of a module targeting interpersonal problems and emotional processing. Eighty-three primarily White participants (mean age = 37) with a principle diagnosis of GAD were recruited from the community. Participants were assigned randomly to CBT plus supportive listening (n = 40) or to CBT plus interpersonal and emotional processing therapy (n = 43) within a study using an additive design. Doctoral-level psychologists with full-time private practices treated participants in an outpatient clinic. Using blind assessors, participants were assessed at pretreatment, posttreatment, 6-month, 1-year, and 2-year follow-up with a composite of self-report and assessor-rated GAD symptom measures (the Penn Results-Mixed models analysis of all randomized participants showed very large withintreatment effect sizes for both treatments , d = 1.86) with no significant differences at post .07], d = .07) or 2-year follow-up (CI = [-.01, .01]), d = .12). There was also no statistical difference between compared treatments on clinically significant change based on chi-square analysis.State Conclusions-Interpersonal and emotional processing techniques may not augment CBT for all GAD participants.Keywords generalized anxiety disorder; emotional processing; emotional avoidance; interpersonal problems; cognitive-behavioral therapy On the basis of several clinical trials (see , cognitive-behavioral therapy (CBT) presently stands as the only psychotherapy to meet criteria as an empirically supported treatment for generalized anxiety disorder (GAD; Chambless & Ollendick, 2001 NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author ManuscriptNonetheless, significant room for improvement exists. A marked percentage of clients continue to experience clinically significant anxious symptoms after treatment (Borkovec & Ruscio, 2001) and fail to demonstrate sustained reduction in GAD symptoms (Westen & Morrison, 2001).Failure to achieve and/or maintain gains from CBT for GAD might be due to the omission of techniques to address variables that may be maintaining the disorder. Among such variables, both emotional processing avoidance and interpersonal problems are prevalent in people with GAD, and researchers have provided well-developed models for their roles in the maintenance of worry and GAD (e.g., Borkovec, Alcaine, & Behar, 2004;Newman & Erickson, 2010). In one of these models, worry, the central feature of GAD, is hypothesized to be a means to avoid emotional processing . In line with this model, the predominantly verbal-linguistic nature of worrisome thinking (and its lessened concrete imagery) inhibit cardiovascular response to feared material, leading to a dampening of emotional learning and a maintenance of worrisome thinki...

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The contrast avoidance model (CAM) suggests that worry increases and sustains negative emotion to prevent a negative emotional contrast (sharp upward shift in negative emotion) and increase the probability of a positive contrast (shift toward positive emotion). In Study 1, we experimentally validated momentary assessment items (N = 25). In Study 2, participants with generalized anxiety disorder (N = 31) and controls (N = 37) were prompted once per hour regarding their worry, thought valence, and arousal 10 times a day for 8 days. Higher worry duration, negative thought valence, and uncontrollable train of thoughts predicted feeling more keyed up concurrently and sustained anxious activation 1 hr later. More worry, feeling keyed up, and uncontrollable train of thoughts predicted lower likelihood of a negative emotional contrast in thought valence and higher likelihood of a positive emotional contrast in thought valence 1 hr later. Findings support the prospective ecological validity of CAM. Our findings suggest that naturalistic worry reduces the likelihood of a sharp increase in negative affect and does so by increasing and sustaining anxious activation.

Worry, rumination, and obsessive thinking are theorized to differ on temporal orientation, positive perceived function, degree of intrusiveness, and discordance with one's self-concept. However, prior findings with respect to such differences may be due to method variance of the measures used and/or inclusion of items confounded by diagnostic symptoms. Accurately capturing differences between types of perseverative thought linked to psychopathology and understanding whether such aspects are common across disorders or specific to some may be important to designing effective treatments for them. Two studies are presented detailing the development and validation of the Perseverative Cognitions Questionnaire (PCQ). The PCQ is a 45-item self-report measure that assesses six dimensional characteristics of worry, rumination, and obsessive thinking previously found to discriminate these thought styles: Lack of Controllability, Preparing for the Future, Expecting the Worst, Searching for Causes/Meaning, Dwelling on the Past, and Thinking Discordant with Ideal Self. Factor structure of the PCQ was established using principal components, exploratory factor, and confirmatory factor analyses. PCQ scales exhibited differential convergence with measures of perseverative thought and psychopathology. The PCQ also demonstrated acceptable retest correlations across 1- and 2-week periods, and incremental validity when predicting symptoms of anxiety, depression, and obsessive compulsive disorder.

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Managing depression and anxiety during pregnancy and the postpartum period is challenging. Both pharmacological treatment and the lack thereof can pose threats to a fetus. SSRIs are the drugs of choice for use during pregnancy, but there is considerable evidence for the safety and efficacy of older antidepressants during pregnancy as well. This study highlights a single case of the use of the tricyclic nortriptyline during pregnancy and postpartum. The subject involved had an unexpectedly high ratio of serum level to drug dose during the postpartum period. We monitored the subject for a significantly greater portion of the postpartum period than has been done in previous studies, and explored medical and lifestyle changes that could account for the level-to-dose ratios we observed. Differences in smoking patterns, coupled with the patient’s status as a genetic poor metabolizer, were the most likely explanations.