Generalized Anxiety Disorder (GAD) is a chronic condition characterized by excessive, uncontrollable worry about various life domains, accompanied by restlessness, fatigue, irritability, muscle tension, and sleep disturbances.
Acceptance and Commitment Therapy (ACT) is a psychological intervention that aims to increase psychological flexibility through six core processes:
- Acceptance: embracing thoughts and feelings without trying to change them
- Cognitive defusion: observing thoughts objectively without getting caught up in them
- Present moment awareness: focusing on the here-and-now experience
- Self-as-context: recognizing the self as the observer of thoughts and feelings
- Values: clarifying what truly matters and gives life meaning
- Committed action: taking effective actions guided by one’s values
ACT may be suitable for GAD because it targets experiential avoidance, cognitive fusion, and values-inconsistent behaviors, which are common maintaining factors in GAD. By cultivating acceptance, mindfulness, and valued living, ACT can help reduce the impact of anxiety.
Ara, B. S., Khosropour, F., & Zarandi, H. M. (2023). Effectiveness of acceptance and commitment therapy (act) on emotional processing, irrational beliefs and rumination in patients with generalized anxiety disorder. Journal of Adolescent and Youth Psychological Studies (JAYPS), 4(4), 34-44. https://doi.org/10.61838/kman.jayps.4.4.5
Key Points
- This study investigated the effectiveness of Acceptance and Commitment Therapy (ACT) on emotional processing, irrational beliefs and rumination in patients with generalized anxiety disorder (GAD).
- Factors like emotional processing deficits, irrational beliefs, and rumination significantly contribute to the development and maintenance of GAD.
- The research found that ACT significantly improved emotional processing, reduced irrational beliefs, and decreased rumination in GAD patients compared to a control group.
- The study provides support for ACT as a promising treatment for addressing key cognitive and emotional factors in GAD, though it had some limitations like a small sample size.
- GAD is a prevalent and impairing disorder worldwide, so identifying effective psychological treatments is universally important.
Rationale
Generalized anxiety disorder (GAD) is a common, chronic and costly emotional disorder that impairs quality of life and functioning.
Several biological, cognitive, behavioral and emotional risk factors are involved in GAD development, including deficits in emotional processing, which is considered a core mechanism (McNamara et al., 2016).
Irrational beliefs and rumination also play a key role in creating and perpetuating GAD through negative cognitive appraisals.
While pharmacotherapy alone is insufficient to address all of the complex, multidimensional issues in GAD, psychological treatments in conjunction with medication may enhance outcomes and prevent relapse. Acceptance and commitment therapy (ACT) is one treatment that has shown promise for anxiety disorders.
However, no prior studies have specifically examined ACT’s impact on emotional processing, irrational beliefs and rumination in GAD patients. This study sought to address that research gap and investigate ACT’s effectiveness in targeting those key cognitive-emotional factors to inform GAD treatment.
Method
Procedure
Patients with GAD were recruited from daily psychiatric treatment centers in Golpayegan, Iran in early 2019.
30 eligible participants were selected based on inclusion and exclusion criteria and randomly allocated to an ACT treatment group (n=15) or control group (n=15).
The ACT group attended 8 weekly ACT therapy sessions lasting 90 minutes each, focused on core ACT processes like acceptance, cognitive defusion, present-moment awareness, self-as-context, values, and committed action.
The control group did not receive the ACT intervention during the study period. All participants completed study measures before and after the intervention phase.
Sample
Participants were 30 adult outpatients (aged 18+) diagnosed with GAD by a psychiatrist. They were required to have at least a high school diploma level of education.
People were excluded if they had disease recurrence, hospitalization, or a physical illness preventing attendance, missed 3+ sessions, or experienced unforeseen accidents during the study.
Measures
- Spitzer’s Generalized Anxiety Disorder Scale (2006): This 7-item scale assesses the severity of GAD symptoms experienced over the past 2 weeks, including excessive anxiety, difficulty controlling worry, restlessness, irritability, and sleep disturbance. Higher scores indicate greater GAD symptom severity.
- Baker Emotional Processing Scale (2007): This scale measures deficits in emotional processing, which involves the ability to accurately identify, experience, regulate, and express emotions adaptively. It assesses dimensions such as emotional awareness, expression, and regulation, with higher scores reflecting greater difficulties in effectively processing emotions.
- Jones Irrational Beliefs Questionnaire (1968): This questionnaire assesses the extent to which an individual holds various irrational beliefs, which are rigid, extreme, and unrealistic cognitive appraisals that contribute to emotional distress. These beliefs often involve themes of demandingness, awfulizing, low frustration tolerance, and global self-rating. Higher scores indicate a greater endorsement of irrational beliefs.
- Nolen-Hoeksema & Morrow’s Rumination Questionnaire (1991): This measure assesses the tendency to engage in rumination, which is a maladaptive cognitive process involving repetitive and passive focus on one’s symptoms of distress and their possible causes and consequences. It captures dimensions such as brooding and reflection, with higher scores indicating a greater propensity to ruminate in response to negative mood states.
Statistical Analysis
The data were analyzed using analysis of covariance (ANCOVA) with SPSS-24 software. ANCOVA compared the post-treatment scores of the ACT and control groups on the dependent variables while controlling for pre-treatment scores.
Results
The ANCOVA results showed that compared to the control group, the ACT group had significantly greater improvements in:
- Emotional processing (p<0.001)
- Irrational beliefs (p<0.001)
- Rumination (p<0.001)
This indicates ACT was effective at enhancing emotional processing abilities, reducing irrational thinking, and decreasing ruminative tendencies in GAD patients.
Insight
This study provides insight into how acceptance and commitment therapy can effectively target several important cognitive and emotional factors involved in generalized anxiety disorder.
By increasing acceptance, diminishing cognitive fusion with anxious thoughts, enhancing present-focused awareness, and promoting action aligned with values, ACT was able to significantly improve patients’ ability to adaptively process emotions, decrease irrational beliefs that exacerbate anxiety, and reduce maladaptive rumination.
This builds on prior research showing ACT’s benefits for anxiety while uniquely demonstrating its impact on the specific mechanisms of emotional processing, irrational beliefs, and rumination in GAD.
The findings suggest targeting those factors in an acceptance and mindfulness-based approach can lead to significant clinical gains.
Future studies should replicate this with larger samples while examining longer-term effects and mediating variables. Therapy-component research would also clarify the active ingredients.
Overall, this study points to ACT’s promise as an effective, process-based therapy for generalized anxiety disorder.
Strengths
The study had several methodological strengths:
- Use of a randomized controlled design with pre-post assessment
- Manualized ACT intervention delivered by trained therapists
- Selection of GAD-diagnosed participants based on clinical assessment
- Valid, reliable outcome measures of key constructs
- Appropriate statistical analysis plan
Limitations
Some limitations should be noted:
- The sample size was relatively small, limiting generalizability. Larger replication studies are needed.
- The sample lacked ethnic diversity as participants were recruited from one region in Iran. Results may not generalize to other cultural contexts.
- The study lacked a long-term follow-up assessment. The durability of ACT’s effects is unclear.
- The control group received no intervention or placebo, so some effects could be due to nonspecific factors. An active treatment comparison group would be informative.
Implications
This study has significant clinical implications, suggesting acceptance and commitment therapy may be an effective treatment choice for generalized anxiety disorder.
By targeting emotional processing deficits, irrational beliefs, and rumination – key factors in GAD’s onset and persistence – ACT provides an avenue for meaningful symptom relief and improved functioning.
The findings support training therapists in ACT for GAD and making it more widely available, especially given the high prevalence and healthcare costs of the disorder.
Still, individual patient characteristics and preferences should guide treatment selection, and ACT should be integrated with other evidence-based approaches like pharmacotherapy.
Policymakers and mental health organizations may look to this research to inform treatment guidelines and recommendations for GAD.
Further research is still needed on ACT’s efficacy and mechanisms across diverse GAD samples to refine its clinical application.
References
Primary reference
Ara, B. S., Khosropour, F., & Zarandi, H. M. (2023). Effectiveness of acceptance and commitment therapy (act) on emotional processing, irrational beliefs and rumination in patients with generalized anxiety disorder. Journal of Adolescent and Youth Psychological Studies (JAYPS), 4(4), 34-44. https://doi.org/10.61838/kman.jayps.4.4.5
Other references
MacNamara, A., Kotov, R., & Hajcak, G. (2016). Diagnostic and symptom-based predictors of emotional processing in generalized anxiety disorder and major depressive disorder: An event-related potential study. Cognitive therapy and research, 40, 275-289. https://doi.org/10.1007/s10608-015-9717-1
Keep Learning
Here are some questions for a college class to discuss this paper:
- What are the key cognitive and emotional factors that contribute to generalized anxiety disorder? How does ACT aim to target these factors based on its treatment model?
- Considering the study’s limitations, what further research would help clarify or strengthen the findings on ACT for GAD? How could future studies improve upon the methodology?
- How might cultural factors influence the manifestation and treatment of GAD and the appropriateness of ACT? What cultural adaptations, if any, would make ACT more relevant for diverse groups?
- The study used therapist-delivered ACT, but could self-help or digital versions be effective for GAD as well? What benefits and drawbacks might those formats have compared to in-person therapy?
- Given the multifaceted nature of GAD, what other evidence-based treatment elements could potentially combine well with ACT to optimize outcomes? How should clinicians decide on combination vs. monotherapy approaches?
