Challenging GAD with Mindfulness

TOPIC: psychology, peer-reviewed research

RECENT results from a small pilot study by Susan Evans & colleagues (2008, see full citation and summary below) add to the growing literature on the efficacy of mindfulness-based approaches to various psychological disorders, in this case applied to generalized anxiety disorder (GAD), a disabling anxiety disorder characterized by chronic anxiety and associated physical symptoms in the face of little-or-no provocation (see, e.g. the NIMH site on GAD).

Mindfulness-based cognitive therapy (MBCT), perhaps best described in Segal, Williams, & Teasdale’s (2002) book Mindfulness-Based Cognitive Therapy For Depression, combines elements of cognitive therapy and mindfulness-based stress reduction (MBSR) originally pioneered by Jon Kabat-Zinn (see Full Catastrophe Living, 1990). Cognitive Therapy, or Cognitive-Behavioral Therapy (CBT), in general seeks to challenge a patient’s cognitive distortions (such as all-or-nothing thinking, labeling, etc). On the other hand, Kabat-Zinn describes mindfulness as "paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally" (see e.g. Kabat-Zinn’s Wherever You Go, There You Are, 1994). Combined in MBCT, participants learn to reflect nonjudgmentally on their own thought, a metacognitive process in which participants treat their thoughts as thoughts per se rather than reality and in which participants train themselves in attentional control.

Evans & colleagues point out that, although CBT is an effective treatment for GAD,

… GAD nonetheless remains the least successfully treated of the anxiety disorders (Brown, Barlow, & Liebowitz, 1994). Ninan (2001) points out that nearly twice as many patients in treatment for GAD achieve partial remission as those who achieve full remission and indicates the persistence of residual symptoms in many who respond to treatment. [pg 717]

But what’s the motivation to try MBCT for GAD? Why would we think that mindfulness training might complement and possibly enhance CBT treatment for GAD through mindfulness-based cognitive therapy? After all, attentional training is a big component of mindfulness training, and it’s superficially counterintuitive to suggest we should increase the attentional awareness of patients with GAD &mdash aren't they essentially too aware already?

Not necessarily. And mindfulness training isn't really about increasing awareness per se (although it can certainly have that effect). Instead, mindfulness is an exercise in attentional control. In this sense, there are several plausible mechanisms for the palliative effect of mindfulness training, including (1) the ability to redirect attention away from troubling thoughts; (2) the ability to relate to thoughts as thoughts instead of true reflections of reality; and (3) the redirection/redistribution of cognitive resources (i.e.thinking about one thing makes it difficult to think about some other thing). Evans’ team reminds us:

Roemer and Orsillo (2002) point out that since the nature of worry is future directed, training in present-moment mindful awareness may provide a useful alternative way of responding for individuals with GAD. Astin (1997) suggests that the techniques of mindfulness meditation help the person to develop a stance of detached observation towards the contents of consciousness and may be a useful cognitive behavioral coping strategy. [pg 217]

The results of the pilot study are consistent with MBCT being helpful in treating GAD, although firm conclusions aren’t possible from this non-experimental design. A summary of the paper appears below.

Article Summary

SOURCE:

EVANS, S., FERRANDO, S., FINDLER, M., STOWELL, C., SMART, C., HAGLIN, D. (2008). Mindfulness-based cognitive therapy for generalized anxiety disorder. Journal of Anxiety Disorders, 22(4), 716-721. DOI: 10.1016/j.janxdis.2007.07.005

General Methodology	Small, pre-test post-test, non-experimental pilot study. No control group. Participants screened for inclusion/exclusion criteria, but otherwise self-selected.
Participants and Sample Size(s)	11 (6 female, 5 male), mean age = 49 yrs, mean educ = 17 yrs, resulting from first screening 36 applicants down to 12, then dropping 1 from data analysis due to unrelated medical problem.
Conditions/Manipulations	8-week mindfulness-based cognitive therapy (MBCT) program
Dependent Measures included	Beck Anxiety Inventory (BAI); Beck Depression Inventory (BDI); Penn State Worry Questionnaire (PSWQ); Profile of Mood States (POMS); Mindfulness Attention Awareness Scale (MAAS)
Other Measures	Anecdotal participant self-reports.
Results
Before MBCT:  moderate levels of anxiety (BAI); pathological degree of worry (PSWQ); significant levels of anxiety and tension (POMS); mild levels of depression (BDI); & mindful awareness significantly lower than normal (MAAS) After MBCT:  statistically significant improvement on all scales except the MAAS; MAAS scores improved to approximately normal, though the change didn't reach statistical significance (probably due to small sample size); all participants completed the 8-week MBCT course; very positive anecdotal stories from participants.
Discussion/Conclusions
MBCT appears to be "a feasible and acceptable treatment for individuals with GAD" [pg 720]; stronger conclusions not possible because of non-experimental design, and external validity (generalizability) difficult to assess.

Related references.

Astin, J. A. (1997). Stress reduction through mindfulness meditation: effects on psychological symptomatology, sense of control and spiritual experiences. Psychotherapy and Psychosomatics, 66(2), 97–106.

Brown, T., Barlow, D., & Liebowitz, M.(1994). The empirical basis of generalized anxiety disorder. American Journal of Psychiatry, 151, 1272–1280.

Kabat-Zinn, J. (1990) Full Catastophe Living. New York: Delta Publishing.

Ninan, P. T. (2001). General anxiety disorder: why are we failing our patients? Journal of Clinical Psychiatry, 62(Suppl. 19), 3–4.

Roemer, L., & Orsillo, S. M. (2002). Expanding our conceptualization of and treatment of generalized anxiety disorder: integrating mindfulness/acceptance-based approaches with existing cognitive-behavioral models. Clinical Psychology: Science and Practice, 9(1), 54–68.