Background: Worry exposure (WE) is a core element of cognitive-behavioral treatment for generalized anxiety disorder (GAD). Its efficacy as a stand-alone treatment method (without further cognitive-behavioral therapy interventions) has never been tested.We aimed to examine whether WE alone is as efficacious as the empirically supported stand-alone treatment for GAD, applied relaxation (AR). Methods: In a randomized controlled study, 73 outpatients meeting DSM-IV criteria for GAD as primary diagnosis were allocated to either WE or AR or a waiting list control group; in a 2nd randomization procedure the waiting list subjects were reallocated to WE or AR. The treatment was manualized (15 sessions with WE or AR), included 6-month and 1-year follow-ups, as well as last observation carried forward and completer analyses, and was controlled for allegiance effects.The Hamilton Anxiety Rating Scale and the State-Trait Anxiety Scale were used as primary outcome measures. Self-report scales of anxiety, worrying and depression including negative metacognition about worrying and thought suppression served as secondary outcome measures. Results: The dropout rate was moderate. The pre-/posttreatment effects were high for the Hamilton Anxiety Rating Scale (standardized mean difference >1) and for the State-Trait Anxiety Inventory (standardized mean difference >0.87). The proportion of patients reaching high end state functioning was 48% (WE) and 56% (AR). WE and AR did not differ with regard to dropout rate or treatment effects. The treatment effects were stable at 6 month and 1 year follow-up. Conclusion: This is the first study to show that a stand-alone exposure in sensu technique – WE – is efficacious in the treatment of GAD. Both AR and WE seem to represent effective principles of change in GAD.

Kessler RC, Chiu WT, Demler O, Walters EE: Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:617–627.
Wittchen HU, Hoyer J: Generalized anxiety disorder: nature and course. J Clin Psychiatry 2001;62(suppl 11):15–21.
Wittchen HU, Kessler RC, Beesdo K, Krause P, Höfler M, Hoyer J: Generalized anxiety and depression in primary care: prevalence, recognition, and management. J Clin Psychiatry 2002;63(suppl 8):24–34.
Yonkers KA, Bruce SE, Dyck IR, Keller MB: Chronicity, relapse, and illness – course of panic disorder, social phobia, and generalized anxiety disorder: findings in men and women from 8 years of follow-up. Depress Anxiety 2003;17:173–179.
Fava G, Ruini C, Rafanelli C: Well-being therapy for generalized anxiety disorder. Psychother Psychosom 2005;74:26–30.
Linden M, Zubrägel D, Bär T, Franke U, Schlattmann P: Efficacy of cognitive behaviour therapy in generalized anxiety disorders. Psychother Psychosom 2005;74:36–42.
Mitte K: Meta-analysis of cognitive-behavioral treatments for generalized anxiety disorder: a comparison with pharmacotherapy. Psychol Bull 2005;131:785–795.
Hunot V, Churchill R, Silva de Lima M, Teixeira V: Psychological therapies for generalised anxiety disorder (review). Cochrane Database Syst Rev 2007;1:CD001848.
Ballenger JC, Davidson JRT, Lecrubier Y, Nutt DJ, Borkovec TD, Rickels K, Stein MD, Wittchen HU: Consensus statement on generalized anxiety disorder from the International Consensus Group on Depression and Anxiety. J Clin Psychiatry 2001;62(suppl 11):53–58.
Borkovec TD, Ray WJ, Stoeber J: Worry: a cognitive phenomenon intimately linked to affective, physiological, and interpersonal behavioral processes. Cognit Ther Res 1998;22:561–576.
Foa EB, Kozak MJ: Emotional processing of fear: exposure to corrective information. Psychol Bull 1986;99:20–35.
Barlow DH, Rapee RM, Brown TA: Behavioral treatment of generalized anxiety disorder. Behav Ther 1992;23:551–570.
Borkovec TD, Costello E: Efficacy of applied relaxation and cognitive-behavioral therapy in the treatment of generalized anxiety disorder. J Consult Clin Psychol 1993;61:611–619.
Öst LG: Applied relaxation: description of a coping technique and review of controlled studies. Behav Res Ther 1987;25:397–409.
Öst LG, Breitholtz E: Applied relaxation vs. cognitive therapy in the treatment of generalized anxiety disorder. Behav Res Ther 2000;38:777–790.
Tryon WW: Possible mechanisms for why desensitization and exposure therapy work. Clin Psychol Rev 2004;25:67–95.
Wells A: A metacognitive model and therapy for generalized anxiety disorder. Clin Psychol Psychother 1999;6:86–95.
Wittchen HU, Pfister H: DIA-X Interview. Frankfurt, Swets & Zeitlinger, 1997.
Becker E, Margraf J: Generalisierte Angststörung. Ein Therapieprogramm. Weinheim, Beltz, 2002.
World Health Organization: Composite International Diagnostic Interview (CIDI). Geneva, World Health Organization, Division of Mental Health, 1990.
Hamilton M: The assessment of anxiety states by rating. Br J Med Psychol 1959;32:50–55.
Hamilton M: A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56–62.
Laux L, Glanzmann P, Schaffner P, Spielberger CD: State-Trait-Angstinventar (STAI). Weinheim, Beltz, 1981.
Meyer TE, Miller ML, Metzger RL, Borkovec TD: Development and validation of the Penn State Worry Questionnaire. Behav Res Ther 1990;28:487–495.
Stöber J: Besorgnis: ein Vergleich dreier Inventare zur Erfassung allgemeiner Sorgen. Z Diff Diagn Psychol 1995;16:50–63.
Cartwright-Hatton S, Wells A: Beliefs about worry and intrusions: the Meta-Cognitions Questionnaire and its correlates. J Anxiety Disord 1997;11:279–296.
Hoyer J, Gräfe K: Meta-Kognitions-Fragebogen (unpublished manuscript). Dresden, Technische Universität Dresden, 1999.
Wegner DM, Zanakos S: Chronic thought suppression. J Pers 1994;62:615–640.
Höping W, deJong-Meyer R: Differentiating unwanted intrusive thoughts from thought suppression: what does the White Bear Suppression Inventory measure? Pers Individ Dif 2003;34:1049–1055.
Hautzinger M, Bailer M, Worall H, Keller F: Das Beck Depressionsinventar. Bern, Huber, 1995.
Franke GH: Brief Symptom Inventory, German version. Weinheim, Beltz, 2000.
Luborsky L, Barber J, Siqueland L, Johnson S, Najavits LM, Frank A, Daley D: The revised helping alliance questionnaire (HAQ-II): psychometric properties. J Psychother Pract Res 1996;3:260–271.
Bassler M, Potratz B, Krauthauser H: The helping alliance questionnaire (HAQ) by Luborsky – possibilities for evaluation of the inpatient psychotherapy treatment process. Psychotherapeut 1995;40:23–32.
Guy W: ECDEU Assessment Manual for Psychopharmacology. Bethesda, National Institute of Mental Health, 1976.
Royall RM: Model robust confidence intervals using maximum likelihood estimators. Int Stat Rev 1986;54:221–226.
Carpenter J, Bithell J: Bootstrap confidence intervals: when, which, what? – A practical guide for medical statisticians. Stat Med 2000;19:1141–1164.
Stata Corp. Stata Statistical Software: release 9.2. College Station, Stata Corporation, 2007.
Doyle AC, Pollack MH: Establishment of remission criteria for anxiety disorders. J Clin Psychiatry 2003;64(suppl 15):40–45.
Dahl AA, Ravindran A, Allgulander C, Kutcher SP, Austin C, Burt T: Sertraline in generalized anxiety disorder: efficacy in treating the psychic and somatic anxiety factors. Acta Psychiatr Scand 2005;111:429–435.
Borkovec TD, Alcaine OM, Behar E: Avoidance theory of worry and generalized anxiety disorder; in Heimberg RG, Turk CL, Mennin DS (eds): Generalized Anxiety Disorder. Advances in Research and Practice. New York, Guilford Press, 2004, pp 77–108.
Simons M, Schneider S, Herpertz-Dahlmann BM: Metacognitive therapy versus exposure and response prevention for pediatric obsessive-compulsive disorder. Psychother Psychosom 2006;75:257–264.
Longmore RJ, Worrell M: Do we need to challenge thoughts in cognitive behavior therapy? Clin Psychol Rev 2007;27:173–187.
Anholt GE, Kempe P, de Haan E, van Oppen P, Cath DC, Smit, JH, van Balkom A: Cognitive versus behavior therapy: processes of change in the treatment of obsessive-compulsive disorder. Psychother Psychosom 2008;77:38–42.
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