2

Evidence-Based Psychological
Treatments for
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Geriatric Anxiety
Shiva G. Ghaed, Catherine R. Ayers,
and Julie Loebach Wetherell

Despite common misconceptions, anxiety appears to be one of the

most prevalent and debilitating psychiatric disorders presenting in the geri-
atric population. The prevalence of anxiety disorders among older adults in
the community is estimated to be approximately 9% (Kessler et al., 2005).
However, morbidity estimation for late-life anxiety is challenging because
of variables that include comorbid medical conditions, increased medica-
tion use, inconsistent assessment, and diversity in the older population itself
(Ayers, Sorrell, Thorp, & Wetherell, 2007). It is likely that there are even
higher numbers of older individuals experiencing symptoms of anxiety that
while not diagnostic, are still clinically significant and cause notable distress
and dysfunction (Himmelfarb & Murrell, 1984). These prevalence rates may
also be underestimates of true population values given the likelihood that
older adults may deny, minimize (Gurian & Minor, 1991), or simply not rec-
ognize anxiety or depressive symptoms (Wetherell, Petkus, et al., 2009).
Generalized anxiety disorder (GAD) and phobias appear to be the most
commonly diagnosed anxiety disorders in the older population (i.e., 10% prev-
alence rate), and they most often present in primary care settings (Beekman
et al., 1998; Flint, 1994; Kessler et al., 2005; Thorp et al., 2009).

http://dx.doi.org/10.1037/13753-002
Making Evidence-Based Psychological Treatments Work With Older Adults, edited by
F. Scogin and A. Shah
Copyright © 2012 American Psychological Association. All rights reserved.
 Late-life anxiety has been linked to a variety of negative outcomes,
including impairments in both physical and psychological functioning.
Older men with anxiety appear to be at higher risk for coronary artery dis-
ease and experience greater mortality (Kawachi, Sparrow, Vokonas, & Weiss,
1994; Van Hout et al., 2004). Anxiety has been linked to substance abuse
(Poikolainen, 2000), polypharmacy (Golden et al., 1999), and overutiliza-
tion of medical services (de Beurs et al., 1999; Stanley, Roberts, Bourland, &
Novy, 2001) in older adults. GAD in particular is associated with increased
somatic complaints, for example, related to gastrointestinal problems and nau-
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sea (Haug, Mykletun, & Dahl, 2002), headaches (Zwart et al., 2003), and
dizziness (Eckhardt-Henn, Breuer, Thomalske, Hoffmann, & Hopf, 2003).
Furthermore, anxiety adversely affects subjective experiences of well-being
and quality of life (QOL) and impacts daily functioning (Brenes, Guralnik,
Williamson, Fried, & Penninx, 2005; Brenes, Guralnik, Williamson, Fried,
et al., 2005; de Beurs et al., 1999; Lenze et al., 2001; Lenze & Wetherell, 2009;
Wetherell, Thorp, et al., 2004). Suicide, in general, increases with age and
may be an even more serious problem in late-life anxiety populations (Pearson
& Brown, 2000; Szanto et al., 1997). Nearly half of older adults with depres-
sion have co-occurring anxiety disorders (Beekman et al., 2000; Lenze et al.,
2000), and suicide risk may be up to 10 times higher in these patients than in
the general population (Khan et al., 2002). For this reason, the assessment of
depression and anxiety should be a priority when evaluating geriatric patients
who present to primary care settings, regardless of their specific complaints.
Medications such as selective serotonin reuptake inhibitors (SSRIs;
Lenze et al., 2005, 2009) are efficacious for geriatric anxiety, and some
data suggest that SSRIs are more effective than psychotherapy (Pinquart &
Duberstein, 2007; Schuurmans et al., 2006, 2009). Yet the impetus for using
evidence-based psychological treatments for anxiety with the older popula-
tion derives from a number of factors. One of the most compelling reasons for
offering psychotherapeutic treatment in lieu of pharmacotherapy is that older
individuals tend to already be taking many medications and often prefer not
to add to a long list due to concerns about side effects and other issues (Weth-
erell, Kaplan, et al., 2004). In addition, there are risks from taking com-
monly prescribed older medications such as benzodiazepines (Klap, Unroe, &
Unutzer, 2003; Mamdani, Rapoport, Shulman, Herrmann, & Rochon, 2005;
Paterniti, Dufouil, & Alperovitch, 2002). Despite more recent evidence of
efficacy and safety of newer medications such as the SSRIs (Lenze et al., 2005,
2009), some evidence suggests that long-term use of these medications may
contribute to bone loss (Diem et al., 2007). Lenze et al. (2005) recommended
integrated treatment for late-life anxiety patients for this reason, and they
suggested taking a more graduated care approach, particularly in the manage-
ment of somaticizing patients.

10    ghaed, ayers, and wetherell

 The Evidence

This section provides an overview of research that supports the use of

specific treatments for anxiety in the geriatric population. A comprehensive
review of the literature was conducted on psychological treatments for older
adults with anxiety, resulting in the identification of several standard EBTs
that have been deemed appropriate and effective for this patient population.
These treatments include cognitive behavioral therapy (CBT), cognitive
therapy, relaxation training, supportive therapy, and bibliotherapy. Recom-
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mendations are also made in regard to whether to enroll a patient in indi-

vidual or group therapy and treatment approaches that may be more effective
in patients with cognitive impairment.

Cognitive Behavioral Therapy

CBT is a general term used to classify a set of psychotherapy modalities

that share in common a focus on how maladaptive thoughts adversely affect
our feelings and behaviors. In a recent review, Ayers et al. (2007) evalu-
ated 10 studies that used CBT for late-life anxiety, eight of which provided
support for this approach (see Table 2.1). Most of these studies included
standard components of psychoeducation, self-monitoring, relaxation train-
ing, thought stopping and thought challenging, and exposure to sources of
anxiety. In addition, some studies also taught problem solving and addressed
issues such as sleep, communication, memory, and life review. Overall, there
was strongest support for the use of CBT with patients who were older and
had a diagnosis of GAD (Ayers et al., 2007). Furthermore, in some studies,
results indicated long-term and sustained improvements in not only anxiety
but also depressive symptoms and QOL (Stanley, Beck, & Glassco, 1996;
Stanley, Beck, et al., 2003; Wetherell, Gatz, & Craske, 2003). A meta-analysis
provided quantitative confirmation that psychotherapy is more effective than
attention placebo and other active control conditions for geriatric anxiety
(Hendriks, Oude Voshaar, Keijsers, Hoogduin, & van Balkom, 2008).
The following section describes nine studies that provide support for CBT
and one study that provides support for cognitive therapy for use with older
anxiety patients. Although the majority of these studies included patients with
only GAD, two studies included patients with several other anxiety disorders
(e.g., panic disorder, social phobia, anxiety disorder not otherwise specified)
in addition to GAD (i.e., Barrowclough et al., 2001; Gorenstein et al., 2005).
In the first study, self-reported depression and anxiety were significantly lower
for patients who received CBT versus those who received supportive therapy
after treatment and at follow-up (Barrowclough et al., 2001). Gorenstein et al.
(2005) compared patients who received medication with those who received

evidence-based treatments for geriatric anxiety    11

 Copyright American Psychological Association. Not for further distribution.

12   
TABLE 2.1
Cognitive Behavioral and Cognitive Therapy for Late-Life Anxiety

Length of Outcome
Authors Sample Conditions Manual treatment measures Findings

Barrowclough N = 55; M age = 1. CBT CBT based on 8–12 ses- BAI, HAMA, CBT group-reduced self-
et al., 2001 72; met criteria 2. ST disorder spe- sions of STAI-T reports of anxiety and
for panic disor- cific models: individual, depression significantly
der (51%), social Clark, 1988; home- more than ST immedi-
phobia (2%), Wells, 1997; delivered ately following treatment
GAD (19%), or and Beck, therapy and during follow-up.
anxiety disorder Emery, &

ghaed, ayers, and wetherell

not otherwise Greenberg,
specified (28%) 1985
Gorenstein N = 42; M age = 1. CBT-MM CBT based on 13 individual STAI-S, STAI-T, CBT-MM experienced sig-
et al., 2005 68; met criteria 2. MM Gorenstein, sessions PSWQ, SCL- nificantly more improve-
for GAD (55%), Papp, & 90 Anxiety and ment than MM alone in
GAD with panic Kleber, 1999 Obsessive- phobic anxiety and OC.
(9%), panic Compulsiveness No difference in worry,
disorder (17%), (OC) state, or trait anxiety.
anxiety disorder
not otherwise
specified (19%)
Keller et al., N = 30; M age 1. CT CT based on 4 weeks, STAI-T, STAI-S CT group showed signifi-
1975a = 68; subjec- 2. WL Ellis & Harper, 2-hr cant declines in irrational
tive reports of 1961 group thinking and anxiety,
­anxiety session whereas WL did not.
per week
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Mohlman et Study 1: N = 27; Study 1: 1. CBT CBT based on 13 individual BAI, SCL-90, Trait Study 1: No immediate dif-
al., 2003 M age = 66; met with problem- Gorenstein, sessions worry, STAI-T, ferences between CBT
criteria for GAD solving skills Papp, & Kle- GADSS and WL. CBT group
Study 2: N = 15; training, daily ber, 1999 significantly reduced
M age = 67; met structure, GAD severity at 6-month
criteria for GAD and sleep follow-up, whereas WL
hygiene; did not.
2. WL Study 2: Enhanced CBT
Study 2: group showed significant
1. Enhanced reduction in anxiety–
CBT with worry and global severity
memory aids; relative to WL.
2. WL
Mohlman & N = 32; M age = 1. CBT CBT based on 13 individual BAI, PSWQ, Intact and improved EF
Gorman, 69; met crite- 2. WL Gorenstein, sessions STAI-T showed significantly
2005 ria for GAD, Papp, & greater decrease than the
had intact EF, Kleber, 1999 WL on worry. Improved
improved EF, EF showed significantly
impaired EF greater decrease than
the impaired EF and WL
on STAI-T.
Stanley et al., N = 48; M age = 1. CBT CBT based on 14 group GADSS, percent- CBT and ST groups both
1996 68; met criteria 2. ST Borkovec & sessions age of day wor- significantly reduced
for GAD Costello, 1993; rying, PSWQ, worry, anxiety, and
and Craske, WS, STAI-T, depression. Gains
Barlow, & HAMA, FQ maintained at 6-month
O’Leary, 1992 follow-up.
Stanley et al., N = 134; M age = 1. CBT Stanley, Diefen- 10 individual PSWQ, GADSS, CBT (vs. EUC) significantly
2009 67; met criteria 2. EUC bach, & sessions SIGH-A, BDI-II, improved worry severity,
for GAD Hopko, 2004 SF-12 (MCS, depressive symptoms,

evidence-based treatments for geriatric anxiety   

PCS) and general mental
health. Similar improve-

13
ment not seen for GAD
severity measure.
(continues)
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TABLE 2.1
Cognitive Behavioral and Cognitive Therapy for Late-Life Anxiety (Continued)
Length of Outcome

14   
Authors Sample Conditions Manual treatment measures Findings

Stanley, N = 85; M age = 1. CBT CBT based on 15 group PSWQ, WS, CBT group showed sig-
Beck, et 66; met criteria 2. Minimal con- Borkovec sessions GADSS, STAI- nificant improvement
al., 2003 for GAD tact control & Costello, T, HAMA on measures of worry,
1993; anxiety, and QOL
Bernstein & relative to control. Gains
Borkovec, maintained at 12-month
1973; Craske, follow-up.
Barlow, &
O’Leary, 1992
Stanley, N = 12; M age = 1. CBT with Stanley, Diefen- 8 individual GADSS, PSWQ, CBT group showed sig-
Hopko, 71; met criteria problem- bach, & sessions BAI nificantly more improve-
et al., 2003 for GAD solving skills Hopko, 2004 ment on GAD severity,
training and worry, and depression

ghaed, ayers, and wetherell

sleep hygiene ratings than usual care.
2. Usual care
Wetherell N = 75; M age = 1. CBT CBT based on 12 group GADSS, percent CBT group showed sig-
et al., 2003 67; met criteria 2. Discussion Craske, sessions of day worrying, nificantly more improve-
for GAD group (DG) Barlow & PSWQ, HAMA, ment on GAD severity,
focused on O’Leary, 1992 BAI worry, depression, and
worry topics QOL than WL. CBT
3. WL equivalent to DG on
all but one measure of
worry. Gains maintained
at 6-month follow-up.
Note. GAD = generalized anxiety disorder; GADSS = Generalized Anxiety Disorder Severity Scale; CBT = cognitive behavioral therapy; CBT-MM = cognitive behavioral
therapy plus medical management for medication taper; MM = medical management; ST = supportive therapy; BAI = Beck Anxiety Inventory; BDI–II = Beck Depression Inven-
tory—II; HAMA = Hamilton Anxiety Rating Scale; SF-12 (MCS, PCS) = Short Form Health Survey (Mental Component scale, Physical Component scale); SIGH-A = Structured
Interview Guide for the Hamilton Anxiety Scale; STAI-T = State–Trait Anxiety Inventory–Trait; EF = executive function; EUC = enhanced usual care; PCS = physical component
summary; MCS = mental component summary; WL = waiting list; STAI-S = State–Trait Anxiety Inventory–State; CT = cognitive therapy; SCL-90 = Symptom Checklist-90;
PSWQ = Penn State Worry Questionnaire; WS = Worry scale; HAMA = Hamilton Anxiety Rating Scale; FQ = Fear Questionnaire; QOL = Quality of life.
aNote that Keller et al., 1975, is CT only.
 both medication and CBT. They found greater improvement in the latter
group for phobic anxiety and obsessive–compulsiveness, although there were
no significant differences between groups for worry, state, or trait anxiety levels.
Several studies examined patients with GAD alone. The most recent
large-scale study provided some support for the efficacy of CBT for GAD
with older primary care patients (Stanley et al., 2009). Although CBT was
not more effective than treatment as usual on interviewer-rated measures of
somatic anxiety symptoms or GAD severity, it was superior on self-reported
symptoms of worry, depression, and QOL.
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Mohlman et al. (2003) conducted two studies in which an enhanced form

of CBT was compared with a wait-list control group. In the first study, CBT
included teaching problem-solving skills, structuring daily activities, and sleep
hygiene, and this group showed significant improvements in GAD symptoms
6 months after treatment versus no improvements in the control group. In the
second study, enhanced CBT included teaching memory aids, and this group
showed improvements in anxiety and worry and overall anxiety symptoms as
compared with the wait-list control group. In a similar study, Stanley, Hopko,
et al. (2003) compared GAD patients in a usual care control group with a group
of patients who received CBT and training in problem-solving skills and sleep
hygiene, and the latter group showed significantly lower worry, depression, and
GAD symptom ratings than controls. Mohlman and Gorman (2005) conducted
a follow-up study that examined patients based on executive functioning status
(i.e., intact, improved, impaired). In this study, the intact and improved groups
reported less worry, and the improved group reported less anxiety (trait) relative
to the impaired and wait-list control groups. Stanley et al. (1996) showed that
patients who received either CBT or supportive therapy improved in terms of
anxiety, worry, and depression scores, and these improvements were maintained
at the 6-month follow-up point. In a subsequent study conducted by Stanley,
Beck, et al. (2003), patients who received CBT (compared with a minimal
contact control group) showed less anxiety and worry and better QOL. Fur-
thermore, these improvements were evident 12 months following treatment.
Finally, Wetherell et al. (2003) compared three groups (i.e., CBT, worry discus-
sion group, wait list) and found reduced GAD, worry, and depressive symptoms,
and increased QOL for CBT patients versus wait-list patients. In addition, simi-
lar improvements were seen in the worry discussion group, and for both groups
these improvements were maintained 6 months posttreatment.

Cognitive Therapy

Ayers et al. (2007) identified three studies that examined cognitive

therapy (i.e., one type of CBT focusing primarily on thoughts and feelings)
for anxiety; however, only one of these studies (i.e., Keller et al., 1975) pro-
vided support for its effectiveness in the geriatric population (see Table 2.1).

evidence-based treatments for geriatric anxiety    15

 In this study, patients who received cognitive therapy were compared with
patients on the wait list and showed significantly less state and trait anxiety
and less irrational thinking than controls. The other two studies provided
more support for the use of relaxation training and supportive therapy over
cognitive therapy (DeBerry, Davis, & Reinhard, 1989; Sallis, Lichstein,
Clarkson, Stalgaitis, & Campbell, 1983). In a study that compared three
treatment groups (i.e., relaxation training, cognitive therapy with pleasant
events scheduling, supportive therapy), patients who received cognitive ther-
apy showed significantly lower heart rates.
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Relaxation Training

Relaxation training, usually involving breathing and meditation and

some form of progressive muscle relaxation (PMR), was shown to be effective
in reducing anxiety in four out of five studies investigated (De Berry, 1981–
1982, 1982; De Berry et al., 1989; Scogin et al., 1992; see Table 2.2). De Berry
(1981–1982, 1982) compared patients who received PMR with patients who
received pseudorelaxation and found that PMR patients reported significantly
less state anxiety, muscle tension, sleep latency, nocturnal awakenings, and
headaches, and these improvements were maintained 10 weeks following treat-
ment. De Berry (1981–1982, 1982) emphasized the importance of practicing
these skills to sustain long-term benefits from treatment. PMR was also more
effective than cognitive therapy in reducing state anxiety, and these results
were also maintained at the 10-week follow-up point (De Berry, 1989). In
addition, Scogin et al. (1992) showed that patients who received PMR or imag-
inal relaxation training were significantly less anxious (state) than wait-list
patients, and improvements were still evident 1 month after treatment. Rickard,
Scogin, and Keith (1994) demonstrated that treatment benefits were evident
1 year following treatment-relaxation training for anxiety.
Thorp et al. (2009) conducted a meta-analysis that compared different
behavioral treatments for geriatric anxiety. As expected, results of the meta-
analysis indicated that some form of behavioral treatment was more effec-
tive than no treatment (i.e., control conditions). Interestingly, the study also
suggested that CBT and relaxation training were comparable, and CBT plus
relaxation training was not superior to relaxation techniques alone. This pro-
vides further support for the benefits of teaching basic relaxation skills to older
patients with anxiety.

Supportive Therapy

Supportive therapy refers to an eclectic approach in which therapy is

patient driven and strives to maintain well-being and reduce distress in the
context of a supportive therapist–patient relationship (see Appendix 2.1 for

16    ghaed, ayers, and wetherell

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TABLE 2.2
Relaxation Training for Late-Life Anxiety
Length of Outcome
Authors Sample Conditions Manual treatment measures Findings

De Berry, 1981– N = 10; M age range 1. PMR Relaxation based Ten 1-hour STAI-S, PMR group showed significant
1982 = 69–84; recent 2. Pseudo­relaxation on Wolpe, group ses- STAI-T improvement on state anxiety,
widows with sub- 1969; and sions muscle tension, sleep latency,
jective reports of Lazarus, 1966 nocturnal awakenings, and head-
­anxiety aches, whereas pseudorelaxation
did not. At 10-week follow-up,
PMR showed gains on state
anxiety.
De Berry, 1982 N = 36; M age range 1. PMR and imagery Relaxation based Ten STAI-S, Both PMR groups showed signifi-
= 63–79; mostly with follow-up on Wolpe, ­30-minute STAI-T cant improvement on state and
recent widows with 2. PMR and imagery 1969; and group trait anxiety whereas pseudo-
subjective reports without follow-up Lazarus, 1972 ­sessions relaxation did not. Gains main-
of anxiety 3. Pseudo­relaxation tained at 10-week follow-up.
De Berry et al., N = 32; M age = 69; 1. PMR and ­imagery PMR and imag- Twenty STAI-S, PMR group demonstrated signifi-
1989 subjective reports 2. CT with assertive- ery based on 45-minute STAI-T cant decrease in state anxiety,
of anxiety ness training Wolpe, 1969; group whereas pseudorelaxation and
3. Pseudo­relaxation Lazarus, 1972; ­sessions CT did not. Gains maintained at
and DeBerry 10-week follow-up.
1982
Rickard, Sco- N = 27; M age = 68; 1. PMR Relaxation based 4 individual Relaxation Reduction in state and trait anxi-
gin, & Keith, subjective reports 2. Imaginal ­relaxation on Bernstein sessions scale, ety and significant decrease in
1994 (1-year of ­anxiety 3. WL & Borkovec, SCL- psychological symptoms 1 year
follow-up from 1973; and 90-R, after ­treatment.
Scogin et al. Crist, 1986 STAI-S,
[1992] study) STAI-T
Scogin et al., N = 71; M age = 68; 1. PMR Relaxation based 4 individual STAI-S, PMR and imaginal relaxation
1992 subjective reports 2. Imaginal relaxation on Bernstein sessions STAI-T, groups significantly reduced
of ­anxiety 3. WL & Borkovec, SCL-90 state anxiety relative to WL.
1973; and Gains maintained at 1-month

evidence-based treatments for geriatric anxiety   

Crist, 1986 follow-up.

17
Note. PMR = progressive muscle relaxation; STAI-S = State–Trait Anxiety Inventory–State; STAI-T = State–Trait Anxiety Inventory–Trait; CT = cognitive therapy; WL = waiting list;
SCL-90 = Symptom Checklist-90; SCL-90-R = Symptom Checklist-90-Revised.
 reference: Novalis, Rojcewicz, & Peele, 1993). In three studies, Ayers et al.
(2007) found some support for the use of supportive therapy, although data
are inconsistent. Sallis et al. (1983) compared three groups of patients (i.e.,
relaxation training, cognitive therapy, supportive therapy) and found that
patients who received supportive therapy had significantly less trait anxiety
than the other two groups (see Table 2.3). Supportive therapy was compared
with CBT in patients with several different anxiety disorders (i.e., GAD,
panic disorder, social phobia, anxiety disorder not otherwise specified), and
patients receiving CBT showed significantly more improvements in mood
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than those who received supportive therapy (Barrowclough et al., 2001). In

contrast, Stanley et al. (1996) showed that patients who received either CBT
or supportive therapy improved in terms of anxiety, worry, and depression
scores, and these improvements were maintained at the 6-month follow-up
point. Overall, however, supportive therapy has not been shown to be more
effective than CBT or relaxation training.

Bibliotherapy

Bibliotherapy, often used as an adjunct to psychotherapy, integrates the

use of books or other written materials to facilitate change. For subsyndromal
anxiety, bibliotherapy may be a reasonable treatment approach. An inves-
tigation by van’t Veer-Tazelaar et al. (2009) suggested that a stepped-care
approach using bibliotherapy as the first-line treatment strategy was effective
at preventing the onset of anxiety disorders and major depression among
older adults with subsyndromal symptoms at baseline (see Table 2.4).

Individual Versus Group Therapy

Treatment for anxiety can be delivered in either individual or group

formats. Research has provided support for the effectiveness of CBT for late-
life anxiety in group settings (Stanley et al., 1996; Stanley, Beck, et al., 2003;
Wetherell et al., 2003). Benefits to patients in group therapy include those
commonly highlighted, such as normalization, the instillation of hope, altru-
ism and information sharing, cohesiveness and catharsis, and opportunities
to practice social skills and relate interpersonally to others (Yalom & Leszcz,
2005). Older adults are often more isolated and may have fewer relationships
with people, having lost more friends to death and illness. Group therapy can
provide a social outlet for these individuals. Individual therapy is typically
preferable for individuals who are suicidal, homicidal, psychotic, or in crisis,
as well as those who are cognitively impaired. Additionally, some individuals
may have a strong preference for individual psychotherapy.

18    ghaed, ayers, and wetherell

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TABLE 2.3
Supportive Therapy for Late-Life Anxiety

Length of Outcome
Author Sample Conditions Manual treatment measures Findings

Barrowclough N = 55; M age = 72; 1. CBT ST based on 8–12 sessions BAI, HAMA, CBT group reduced
et al., 2001 met criteria for panic 2. ST Woolfe, of individual STAI-T self-reports of anxi-
disorder (51%), 1989 home-delivered ety and depression
social phobia (2%), therapy significantly more
GAD (19%), or than ST imme-
anxiety disorder not diately following
otherwise specified treatment and dur-
(28%) ing follow-up.
Sallis et al., N = 38; M age = 71; 1. Relaxation ST based on Ten 60-min STAI-T ST group signifi-
1983 subjective reports of training Johnson, group sessions cantly reduced trait
anxiety 2. CT with 1972 anxiety. CT with
pleasant pleasant events
events significantly
scheduling reduced heart rate.
3. ST
Stanley et al., N = 48; M age = 68; 1. CBT ST based on 14 group GADSS, per- CBT and ST groups
1996 met criteria for GAD 2. ST Borkovec ­sessions centage of both significantly
& Costello, day worry- reduced worry, anxi-
1993 ing, PSWQ, ety, and depression.
WS, STAI-T, Gains maintained at
HAMA, FQ 6-month follow-up.
Note. CBT = cognitive behavioral therapy; ST = supportive therapy; BAI = Beck Anxiety Inventory; HAMA = Hamilton Anxiety Rating Scale; STAI-T = State–Trait Anxiety
­Inventory–Trait; CT = cognitive therapy; GADSS = Generalized Anxiety Disorder Severity Scale; PSWQ = Penn State Worry Questionnaire; WS = Worry scale; FQ = Fear

evidence-based treatments for geriatric anxiety   

Questionnaire.

19
 Copyright American Psychological Association. Not for further distribution.

20   
TABLE 2.4
Bibliotherapy for Late-Life Anxiety

Length of Outcome
Author Sample Conditions Manual treatment ­measures Findings

van’t Veer- N = 170; M age = 1. Intervention: Lewinsohn Stepped care MINI (6, 12 Intervention
Tazelaar 81; subjects with Preventive et al., over 12 months months), decreased
et al., 2009 subthreshold stepped-care 1984 (4 steps, CES-D (3, 6, incidence rate
symptoms of programa 3 months per 9, 12 months) of anxiety and

ghaed, ayers, and wetherell

depression or 2. Usual care step) depression disor-
anxiety but not program ders by half over
meeting full diag- 1 year, com-
nostic criteria pared with usual
care.
Note. CES-D = Center for Epidemiologic Studies Depression Scale; MINI = Mini International Neuropsychiatric Interview.
aPreventive stepped-care program included: (a) watchful waiting; (b) cognitive behavior therapy–based bibliotherapy; (c) brief cognitive behavior therapy–based problem-

solving therapy; (d) referral to primary care. This is in comparison with the usual care program, which allowed unrestricted access to usual care for depression or anxiety concerns.
 Cognitive Impairment

Patients with cognitive impairment may have difficulty with compo-

nents of CBT that are more abstract or require more information or cognitive
processing. As mentioned previously, strategies taught in some modules may
be more accessible to such patients and should be included in their treatment
programs. Thus, cognitively impaired adults with anxiety may benefit more
from modules that are more personally relevant, concrete, and behaviorally
focused. Relaxation techniques, which are highly effective for anxiety reduc-
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tion, are well-defined and simple exercises that can be easily taught to cogni-
tively impaired patients. Modules that consist of predominantly behavioral
strategies (vs. cognitive processes), such as sleep hygiene guidelines, worry
control exercises, and in vivo exposures, are also likely to be better used by
these patients. Life review can be beneficial because remote personal histori-
cal memory may be intact.

Adapting EBT for the Real World

Shiva G. Ghaed

The purpose of this section is to provide a practical guide for the imple-
mentation of evidence-based treatment in your clinical practice. It should be
noted that the treatment approach outlined in the subsequent sections of this
chapter is adapted primarily to GAD and general anxiety symptoms. There
are several ways in which treatment can be adjusted for a geriatric patient.
First and foremost, caregivers and family members can be included in treat-
ment planning and encouraged to accompany the patient to psychotherapy
sessions. Depending on the stamina of the patient, sessions can be abbrevi-
ated, if necessary, decreasing patient burden. Also, if feasible, home visits can
be made, which remedies problems related to transportation, medical issues,
and lack of initiative, or avoidance.
It is important to recognize that older adults may be new to the psycho-
therapy process, and thus even prior to receiving psychoeducation about
anxiety, they may need general information about the mechanics of psycho-
therapy itself. Establishing good rapport with these patients can be critical to
subsequent adherence to the treatment program. It is my firm belief that one
of the most effective techniques for establishing rapport early on and setting
the stage for productive therapy is providing my patients validation for any
reticence about beginning therapy and addressing any issues related to stigma

evidence-based treatments for geriatric anxiety    21

 associated with mental illness or fears about opening up to a stranger who
they feel may not understand their perspective or life experiences.
As a therapist in the Veterans Affairs health care system, one becomes
all too familiar with patients who present with numerous comorbidities and
complex medical histories. With these and most medical patients, I like to
provide an overview of the topography of anxiety in later life, including prev-
alence statistics, education about the most common anxiety disorders for the
patient’s relevant age group, and typical symptomatology of geriatric anxiety.
In addition, my patients often find it helpful when I provide a description
Copyright American Psychological Association. Not for further distribution.

of current pharmacotherapy and psychotherapy approaches to treatment, as

well a rationale for implementing evidence-based treatments. In addition
to the treatment narrative that follows, I offer a listing of resources and sug-
gested readings on anxiety and various clinical approaches in Appendix 2.1.
Once I have laid the groundwork for psychotherapy with my patient, I
present a general definition and description of CBT. I describe the interre-
lationships among thoughts, emotions, and behaviors and those factors that
serve to maintain them. I explain that one of my goals is to help the patient
achieve a heightened awareness of any patterns that might be occurring
within this triangle and that might be causing distress or negative outcomes
(e.g., alienation, depression). I emphasize that therapy is a collaborative pro-
cess, but also a didactic one, and my patients will be taught how to monitor
internal processes and analyze them in methodical and rational ways. I teach
my patients how cognitive processes can influence feelings by using relevant
examples and then asking them to think of similar scenarios in their own
daily lives. I reassure them that I will help them learn how to properly evalu-
ate and replace self-defeating or maladaptive thought patterns, which in turn
will likely alter the resulting emotions (i.e., more realistic thoughts lead to
more balanced emotions).
One critical element of effective psychotherapy that I emphasize early
on is the need for my patient to be engaged and responsive to homework
assignments. Behavioral change is also a critical component of improving
mood and reducing anxiety. I explain to my patients that in addition to
cognitive restructuring, CBT targets maladaptive behaviors, such as avoid-
ance, that are highly negatively reinforcing and ultimately exacerbate and
perpetuate anxiety. I explain that techniques such as self-monitoring and
the completion of at-home practice assignments in between sessions will
help them accomplish this goal of behavioral change. It should be noted
that homework assignments, in particular, are highly predictive of positive
therapy outcomes. Furthermore, I find that using a Socratic, or open-ended
questioning, approach is more effective than using a lecturing style.
For patients who are not already taking a psychotropic medication, I
discuss with them that such medications may be more effective for many

22    ghaed, ayers, and wetherell

 people than what I have to offer, at least as a first step. I encourage them to
talk about medications with their doctor; I also provide referrals to psychia-
trists with expertise in working with older adults if they are interested in get-
ting the opinion of a specialist. Many patients come to therapy feeling better
but not completely well after taking a medication, and I have had success in
using psychotherapy as an adjunct for patients who still have anxiety or worry
symptoms even with pharmacotherapy. For patients who do not respond to
psychotherapy alone, I engage in motivational interviewing techniques to
encourage a medication trial.
Copyright American Psychological Association. Not for further distribution.

On a final note, ethical principles and standards dictate that profes-

sional psychologists practice within their range of competency, I encourage
clinicians to obtain relevant training in evidence-based treatments prior to
implementing psychotherapy with patients. Specialized training for anxiety
disorders can be obtained at any stage of one’s professional career and in a
variety of ways. Health care providers are encouraged to attend professional
conferences that are not only evidence based in their approach but also whose
focus is on geropsychology. It is recommended that trainees new to this field
join consultation groups or receive supervision from a licensed professional
with expertise in delivering evidence-based treatments to late-life patients.
In addition, there are many well-written manuals that outline evidence-based
psychotherapy for each of the different anxiety disorders (e.g., the Treatments
That Work series published by Oxford University Press; see Appendix 2.1),
and therapists are encouraged to use a more manualized approach during early
stages of learning these treatments. Finally, therapists can obtain multimedia
(e.g., CDs, videotapes) that contain sample interviews with patients who are
using specific psychotherapy modalities.

Case Example

The patient, “Helen,” is a 75-year-old, widowed, Caucasian woman who

presents with anxiety and depressive symptoms (i.e., referred to the clinic
for GAD). Her medical problems include chronic pain, difficulty sleeping,
and severe arthritis. She reports being overly worried about “everything” in
her life, including her daughter’s divorce, her son’s financial troubles, health
problems, and more recently, being asked to help care for her grandchildren.
She is not able to leave her home because she is afraid that her arthritis
will flare up and she will not have a place to rest or that she might injure
herself. She refuses to consider a psychotropic medication but agrees to a
brief course of psychotherapy (i.e., approximately 20 sessions) to help her
learn new ways to cope with her anxiety and the stress of uncontrollable
events around her. As her therapist, I begin a collaborative approach with

evidence-based treatments for geriatric anxiety    23

 her to create a treatment plan that focuses on the most relevant and distress-
ing presenting issues. Appendix 2.2 presents sample outlines for a course of
20 CBT sessions.

Presession 1: Assessment

In the waiting room, Helen is asked to complete a “problem list” (see

Appendix 2.3) to identify sources and levels of distress over the past month.
This will aid me in planning the CBT intervention and identifying the most
Copyright American Psychological Association. Not for further distribution.

relevant problem areas on which to focus most efforts. Patients should also
be asked to complete a measure of anxiety or worry at this time and every
few sessions to track progress. In this case, Helen is provided the eight-item
short form of the Penn State Worry Questionnaire (Meyer, Miller, Metzger,
& Borkovec, 1990), which was developed for older adults and is frequently
used with geriatric GAD patients (see Appendix 2.4). It should be noted
that there are other measures available for use, for example, the GAD-7
(Spitzer, Kroenke, Williams, & Lowe, 2006), the Geriatric Anxiety Inven-
tory (Pachana et al., 2007), and the well-known Beck Anxiety Inventory
(Beck, Epstein, Brown, & Steer, 1988). Assessment results indicated difficul-
ties with sleep, uncontrollable worry, and difficulties solving real-life prob-
lems. As such, a main focus of the intervention included relaxation training,
problem solving, sleep hygiene, and controlling worry. Other interventions
(assertive communication, pleasant activities, acceptance and mindfulness,
and time management) also assisted with Helen’s distressing anxiety symp-
toms as well as supported the use of the main strategies listed above.

Sessions 1–2: Building Rapport and Psychoeducation

During the first session, Helen is provided validation for her problems,
positive feedback for seeking help, and encouragement about the benefits
of therapy, as well as reassurance that this process will be a collaborative
and supportive one. An introduction to therapy includes psychoeducation
to help her recognize the effects of anxiety on her QOL and assess her cur-
rent level of functioning. Together we review her problem list and identify
the most currently impactful issues—her isolation due to multiple medical
problems, difficulty with establishing boundaries with family members, and
coping effectively with events that are out of her control. I supply Helen with
take-home reading, as I do for all of my patients, which includes information
on the prevalence and physiology of anxiety and a description of anxiety dis-
orders. Finally, I emphasize the importance of self-monitoring and at-home
practice. We agree that our next few sessions will focus on basic lifestyle hab-
its that might help to alleviate anxiety, beginning with relaxation training.

24    ghaed, ayers, and wetherell

 I also discuss with Helen the major components of anxiety that will be
the targets of treatment—physical sensations, thoughts–feelings, and behav-
iors. I ask Helen to describe her subjective experience of anxiety and pro-
vide examples of situations in which she has felt anxious or worried in the
recent past. Normalizing anxiety and discussing its adaptive purpose, as well
as offering a general description of the physiological response to anxiety and
fear (i.e., “fight or flight”), can be helpful for patients. I introduce the idea of
anxiety and worry as parts of a vicious cycle that can be broken, and I empha-
size to Helen that anxiety is not dangerous despite subjective experience, and
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that it is also time limited. At the close of the therapy session, I raise the issue
of at-home practice, allowing Helen to direct and determine the negotiation
of this critical therapy component with the hope of increased adherence.
Homework for the remainder of therapy will include thought-tracking forms,
which ask the patient to identify the activating event, automatic thought,
resulting emotions, and any behavioral consequences of the thoughts and
feelings, as well as an anxiety rating (0–10).
Note to therapist: When patients have supportive family members liv-
ing in the area, I always invite family members to attend one of the first few
sessions. Family members can play an important role in treatment and can
also provide useful information about the ways in which anxiety is affecting
the patient’s life.

Sessions 3–5: Relaxation Training

These sessions are devoted to providing Helen with relaxation training

to help her recognize levels of tension in her body when she is feeling anx-
ious and to allow her an opportunity to gain the maximum benefit from the
process. Imagery and guided relaxation are preferable for Helen because of
her chronic severe arthritis, which makes PMR a less feasible option. Imag-
ery provides another effective technique for patients to relax by offering an
opportunity to daydream or remember pleasant or peaceful places or experi-
ences. Realism and elaboration are encouraged, and patients are asked to
use all of their senses when engaging in imagery. I provided Helen with an
audiotape of a guided relaxation exercise to help her with at-home practice,
in addition to a sample script (see Appendix 2.5).
Note to therapist: Adequate time should be allotted for relaxation train-
ing given its more immediate effects on anxiety. It is typically taught during
earlier stages of treatment and typically includes teaching techniques such as
diaphragmatic (or deep) breathing, PMR, and guided imagery.
Relaxation training is the most effective component of CBT for geriatric
anxiety (Thorp et al., 2009). For this reason, I usually spend several sessions
on this component and carefully assess changes in anxiety levels during the

evidence-based treatments for geriatric anxiety    25

 weeks devoted to relaxation practice. With patients who do not achieve
substantial benefit, I problem solve; often they are not spending enough
time practicing, and I will use motivational interviewing techniques to
increase their at-home practice. Even with consistent practice, however,
some patients do not respond. For patients in this category who are not cur-
rently taking anxiolytic medication, I initiate another discussion about the
benefits of pharmacotherapy before attempting additional psychotherapeutic
techniques.
In Helen’s case, she has some success practicing her newly acquired
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relaxation techniques. She provides positive feedback about its effectiveness,

although she did not practice as much as she had originally intended. We
briefly discuss what might be hindering her from practicing relaxation more
often (e.g., twice daily), and I emphasize the importance of practice in order
to establish a new habit in one’s life.

Sessions 6–8: Problem Solving

Next, Helen is introduced to the idea of problem solving as an integral

part of daily functioning. She learns that her anxiety is a barrier to effective
problem solving not only because anxiety depletes her of energy required to
reason through problems but also because it increases the likelihood of her
engaging in unproductive worry. Using personal examples she has shared, I
point out that she worries about unlikely and catastrophic events and then
engages in unwanted or undesirable behaviors (e.g., worst-case scenarios
about the possibility of injury prevent her from leaving her home).
Note to therapist: The SOLVE approach is an easily recalled and use-
ful technique that can be presented to the patient (Wetherell, Ayers, et al.,
2009). SOLVE stands for the following steps for problem solving: Select a
Specific problem (i.e., one that can be solved and is not too large or vague),
Outline possible solutions (i.e., brainstorm all possible solutions), List pros–
cons of the two best solutions, Visualize a plan for the best solution (i.e., con-
sider timeline, resources needed), and Evaluate the outcome of the solution
chosen. (See Appendix 2.6 for a sample worksheet.)
I typically introduce problem solving right after relaxation and continue
to include problem-solving homework assignments through the entire course
of therapy. I also encourage patients to continue their relaxation practice.

Session 9: Sleep Hygiene

We move on to the next basic lifestyle issue—sleep—and we evaluate

Helen’s current sleep habits. I instruct her on basic sleep hygiene techniques
to alleviate sleep-related problems. One set of basic guidelines for sleep that

26    ghaed, ayers, and wetherell

 can be easily recalled uses the acronym DROWSE (Wetherell, Ayers, et al.,
2009). These important rules are as follows: Don’t nap during the day; Restrict
awake time in bed to 15 minutes (i.e., if patient is not asleep after 15 minutes
of lying in bed, encourage the patient to get up and engage in a relaxing activ-
ity until the onset of sleepiness); Outdoor light (i.e., getting outside in the
afternoon) can help regulate the sleep–wake cycle; Within 3 hours of bed-
time, refrain from the use of alcohol, caffeine, heavy meals, or exercise; Sleep
and sex should be the only activities done in bed; and Establish a sleep–wake
schedule (anchoring sleep by consistent morning-awakening time). Helen
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is asked to begin self-monitoring and a self-evaluation of her actual sleep hab-

its so that we might be able to identify and change current problem behaviors
that are likely contributing to her sleep difficulties.
Note to therapist: Sleep-related issues are common and should be given
adequate attention with late-life anxiety patients. Patients should be taught
that sleep deprivation is not dangerous despite how distressing it can be, and
most of our “lost” sleep can be made up later. In addition, they should be
informed that performance and cognitive abilities are not as greatly affected as
they might be led to believe by their own subjective assessment. For additional
information on sleep-related issues, please refer to Chapter 3, this volume.

Session 10: Controlling Worry

Every session from here on out begins with a check-in in regard to

Helen’s at-home practices of relaxation, problem solving, and sleep hygiene.
In this session, we discuss how Helen can learn to control her worry through
thought-stopping and stimulus-control techniques. Helen has some diffi-
culty doing this because she sees her life stressors, not her worry, as the
problem. She learns stimulus control by identifying what she worries about
and when she tends to worry about it. She is also encouraged and agrees
to schedule “worry time” (e.g., 30 minutes) at a consistent time and daily.
I encourage her to commit to a specific location in her home for this daily
worry exercise (e.g., designated “worry chair”) to make it more likely that she
engages in the exercise.

Sessions 11–12: Assertiveness and Effective Communication

At this point, Helen shows a comfortable understanding of how her

thoughts, feelings, and behaviors are related. Thus, we move ahead to focus
on other relevant problem areas, specifically assertiveness and effective com-
munication techniques. Helen agrees that this discussion may benefit her
because she has never felt comfortable establishing boundaries that protect
her time or health. We spent ample time in session role playing so that we can

evidence-based treatments for geriatric anxiety    27

 identify aspects of communicating with close family and friends that might
be most challenging to her. We agree on homework for her that includes
practicing her assertiveness skills with a close friend (e.g., saying no to her
daughter when she cannot take care of her grandchildren) and eventually
assertively communicating her needs directly to her daughter.
Note to therapist: Often, older adults with anxiety may communicate
more passively because it enables them to avoid confrontation, and thus they
experience anxiety in social situations. However, the consequences of pas-
sivity can include feelings of low self-esteem and worthlessness and overall
Copyright American Psychological Association. Not for further distribution.

dissatisfaction due to not being able to voice one’s needs or desires. Patients
should be taught the main styles of communication (i.e., passive, aggressive,
assertive), using examples that are personally relevant. Whereas passivity can
lead to withdrawal, aggression can lead to alienation, and both are related
to anxiety. Assertive communication is encouraged as a means for healthier
social interactions in which patients can establish their own needs while also
respecting the needs of others. Use of the SAS technique can help patients
practice assertiveness by: Stating the problem and its consequences (without
judgment or assumptions), Asking for what is needed clearly and directly,
and Spelling out the benefits to the other person of cooperation (Wetherell,
Ayers, et al., 2009).

Sessions 13–14: Increasing Pleasant Activities

The focus of this session is on encouraging Helen to increase the num-

ber of pleasurable activities in her life, which will not only likely improve her
mood but also distract her from her current focus on somatic symptoms and
chronic pain. First, we create a list of pleasant activities that she has enjoyed
in the past or would like to enjoy currently. Second, we discuss what might
be the reasons that she is not engaging in these activities. Finally, we discuss
how her anxiety and fears might be contributing to her diminished involve-
ment in pleasant activities. I emphasize to Helen that another advantage
of engaging in pleasant activities is that it will help disconfirm irrational
thoughts that may be leading to her avoidance of leaving the home or being
more active.
Note to therapist: It can be particularly beneficial to educate patients
who have comorbid depression about the importance of engaging in life
more actively. Patients should be provided psychoeducation on the frequent
comorbidity of anxiety and depression and the similarity in how they func-
tion cognitively and behaviorally. Remind your patient that engaging in pleas-
ant activities offers opportunities for positive reinforcement and provides
them with reward, pleasure, social support, and improved self-esteem. It is
important to note that involvement in a pleasurable activity is more likely to

28    ghaed, ayers, and wetherell

 occur when an individual commits to a clear plan and schedules the activity.
Work with your patients in session to identify activities that they might find
pleasurable, make a plan and set an obtainable goal, and follow through on
that plan.

Sessions 15–16: Acceptance and Mindfulness

One of the areas of distress for Helen is feeling that she has no control
over the events around her. The goal of these sessions is to teach her mind-
Copyright American Psychological Association. Not for further distribution.

fulness strategies that may help her process the idea of acceptance of her cur-
rent life circumstances as well as increased tolerance of the uncontrollable
events in her life. Our discussion of greater acceptance includes all the major
topics in her life: her chronic health conditions, interpersonal problems or
problems that her children are experiencing in their lives, and stage-of-life
transition issues.
Note to therapist: This can be a more intense topic to process with
patients, and for this reason it is recommended for use in the latter sessions
of therapy. Acceptance can also be introduced as an alternative to other
more traditional coping techniques (e.g., relaxation) that can enable an
individual to feel a greater sense of control and comfort with challenging
situations or realities. Patients learn the five main components of awareness,
which are: (a) awareness of the positive aspects of one’s experiences (vs.
getting caught up in the suffering), (b) acknowledgment of the face value of
experiences (vs. associations with past and interpretations about meaning
of events), (c) broader focus (i.e., seeing the big picture vs. focusing on dis-
tress and fears; recognizing values and priorities; setting short- and long-term
goals), (d) distress tolerance (i.e., through distraction, self-soothing, self-
care), and (e) ongoing nature of acceptance process (i.e., requiring commit-
ment to daily practice of skills; Wetherell, Ayers, et al., 2009).

Session 17: Managing Time

Anxiety can result from poor time management, and a large part of
one’s ability to function efficiently and effectively from day to day relies
on the ability to manage daily tasks in a timely fashion. Patients should be
provided basic skills and strategies for time management and encouraged to
know their limits (i.e., how much can be handled in one day or at one time)
and to say no when necessary (i.e., assertive communication). Prioritizing
and delegating (when possible) tasks, as well as planning ahead (i.e., over-
estimating vs. underestimating time needed to accomplish a task) and being
flexible (i.e., eliminating perfectionistic tendencies), can aid in reducing
stress and anxiety.

evidence-based treatments for geriatric anxiety    29

 Sessions 18–20: Maintaining Progress

In Helen’s final therapy sessions, we discuss the great progress she has
made, areas for continued effort, and ways in which she can maintain her
newly acquired coping skills. We carefully review the concepts and strate-
gies she has learned over the duration of therapy. One of the most beneficial
aspects of this phase of therapy is to allow Helen to articulate her perceptions
of therapy progress as well as her specific challenges. Together, we discuss
and ascertain what skills or techniques were least and most used or useful for
Copyright American Psychological Association. Not for further distribution.

her, including how often, when, and where she actually implemented these
techniques. In the final session, Helen and I focus on relapse prevention,
reviewing some of her known triggers, vulnerabilities, and new ways of coping
in these times of crisis. Although she will no longer have homework assigned
to her, I emphasize the importance of solidifying a new healthy habit through
daily practice.

30    ghaed, ayers, and wetherell

 APPENDIX 2.1: Resources and Suggestions
for Further Reading

Antony, M., & Roemer, L. (2011). Theories of psychotherapy series: Behavior therapy.
Washington, DC: American Psychological Association.
Craske, G. M. (2010). Theories of psychotherapy series: Cognitive-behavioral therapy.
Washington, DC: American Psychological Association.
Craske, G. M., & Barlow, D. H. (2006). Treatments that work series: Mastery of your
anxiety and worry (2nd ed.). New York, NY: Oxford University Press.
Copyright American Psychological Association. Not for further distribution.

Davis, M., McKay, M., & Eshelman, E. R. (2008). The relaxation & stress reduction
workbook (6th ed.). Oakland, CA: New Harbinger.
Dobson, K. (2011). Theories of psychotherapy series: Cognitive therapy. Washington,
DC: American Psychological Association.
D’Zurilla, T., & Nezu, A. M. (2006). Problem-solving therapy: A positive approach to
clinical intervention (3rd ed.). New York, NY: Springer.
Laidlaw, K., Thompson, L. W., Gallagher-Thompson, D., & Dick-Siskin, L. (2003).
Cognitive behaviour therapy with older people. Hoboken, NJ: Wiley.
Novalis, P. N., Rojcewicz, S. J., & Peele, R. (1993). Clinical manual of supportive
psychotherapy. Washington, DC: American Psychiatric Press.
Sorocco, K. H., & Lauderdale, S. (in press). Implementing CBT for older adults: Inter-
disciplinary guide. New York, NY: Springer.
Stanley, M. A., Diefenbach, G. J., & Hopko, D. R. (2004). Cognitive behavioral
treatment for older adults with generalized anxiety disorder: A therapist manual
for primary care settings. Behavior Modification, 28, 73–117.
University of Washington, Advancing Integrated Mental Health Solutions. (n.d.)
Impact: Evidence-based depression care. Retrieved from http://impact-uw.org/

General Assessment Instruments

Beck Anxiety Inventory (Beck & Steer, 1993): 21 items, somatic

emphasis; Geriatric Anxiety Inventory (Pachana, Byrne, Siddle, Koloski,
Harley, & Arnold, 2007): 20 items, yes/no format may be helpful for cogni-
tively impaired, newly developed
State–Trait Anxiety Inventory (Spielberger, Gorsuch, & Lushene,
1970): 20 items each subscale, may measure neuroticism more than anxiety

Anxiety and Depression Assessment Instruments

Brief Symptom Inventory-18 (Derogatis, 2001): 6 items each for depres-

sion, anxiety, somatic symptoms on separate subscale
Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983): 7
items each subscale, somatic items omitted

evidence-based treatments for geriatric anxiety    31

 Specialized Assessment Instruments

PTSD Checklist (Blanchard, Jones-Alexander, Buckley, & Forneris,

1996): 17 items, 6-item short form
GAD-7 (Spitzer, Kroenke, Williams, & Bernd Löwe, 2006): 7 items,
assesses worry plus some associated symptoms
Penn State Worry Questionnaire (Meyer, Miller, Metzger, & Borkovec,
1990): 16- and 8-item forms, measures pathological worry rather than GAD,
per se, heavily used in research
Copyright American Psychological Association. Not for further distribution.

Fear Questionnaire (Marks & Mathews, 1979): 5 items per subscale,

agoraphobia, blood-injury phobia, social phobia
Obsessive-Compulsive Inventory–Revised (Foa, 2002): 16 items,
OCD symptoms
Savings Inventory–Revised (Frost, Steketee, & Grisham, 2004): 23
items, 3 subscales for clutter, acquisition, and ability to discard

Organizational Websites

Anxiety Disorders Association of America: http://www.adaa.org

Association for Behavioral and Cognitive Therapies: http://www.abct.org
International OCD Foundation: http://www.ocdfoundation.org

Research and Training Sites

Late-life anxiety research program: Melinda Stanley, PhD, Menninger

Department of Psychiatry and Behavioral Sciences, Baylor College of Medi-
cine, http://www.bcm.edu/psychiatry/anxietycare/
Late-life compulsive hoarding: Catherine Ayers, PhD, ABPP, VA San
Diego Healthcare System/University of California, San Diego, cayers@ucsd.edu
Late-life generalized anxiety and stress: Julie Wetherell, PhD, VA San
Diego Healthcare System/University of California, San Diego, jwetherell@
ucsd.edu
Late-life posttraumatic stress disorder: Steven Thorp, PhD, VA San Diego
Healthcare System/University of California, San Diego, sthorp@ucsd.edu

32    ghaed, ayers, and wetherell

 APPENDIX 2.2: Sample Cognitive Behavioral
Therapy Session Outlines
Sessions 1–2

Establish rapport; provide validation and reassurance.

Review problem list; identify areas of most distress.
Provide psychoeducation about anxiety disorders and treatment.
Provide general outline for therapy process.
Copyright American Psychological Association. Not for further distribution.

Emphasize importance of self-monitoring and at-home practice.

Invite family member to one session if possible.
Elicit reactions to sessions.

Sessions 3–5

Provide relaxation training.

Address issues related to not completing home assignments.
Elicit reactions to sessions.

Sessions 6–8

Review homework (i.e., relaxation techniques, thought–mood

tracking).
Teach strategies for problem solving.
Elicit reactions to sessions.

Session 9

Review homework (i.e., relaxation techniques, problem solving).

Address issues related to not practicing new skills at home.
Teach patient sleep hygiene strategies.
Elicit reaction to session.

Session 10

Review homework (i.e., relaxation techniques, problem solving, sleep

guidelines).
Address issues related to not completing home assignments.
Instruct patient on methods for thought stopping and stimulus control.
Help patient schedule “worry” time.
Elicit reaction to session.

evidence-based treatments for geriatric anxiety    33

 Sessions 11–12

Review homework (i.e., relaxation techniques, worry time, problem

solving).
Address issues related to not completing home assignments.
Teach assertiveness and communication skills.
Role play with patient and assign homework to practice in real life.
Elicit reactions to sessions.
Copyright American Psychological Association. Not for further distribution.

Sessions 13–14

Review homework (i.e., relaxation techniques, worry time, problem

solving, assertiveness skills).
Address issues related to not completing home assignments.
Discuss how to increase pleasant activity scheduling.
Elicit reactions to sessions.

Sessions 15–16

Review homework (i.e., relaxation techniques, thought–mood track-

ing, worry time, problem solving, assertiveness skills, pleasant activities).
Address issues related to not completing home assignments.
Discuss mindfulness and acceptance of uncontrollable events.
Elicit reactions to sessions.

Session 17

Discuss importance of using all skills learned thus far to manage time.
Move toward termination.
Elicit reaction to session.

Sessions 18–20

Review all skills–techniques–strategies learned to date.

Discuss progress made in therapy, areas of continued effort, ongoing
challenges.
Elicit reaction to therapy process.
Final session—termination.

34    ghaed, ayers, and wetherell

 APPENDIX 2.3: Problem List Questionnaire

The following is a list of problems that some older people have. Please indi-
cate how much each problem has bothered you over the past month, using the
following 0–10 scale:

0 1 2 3 4 5 6 7 8 9 10
Copyright American Psychological Association. Not for further distribution.

Not at all A little Somewhat Quite a bit A lot

_____   1. Feeling tense or unable to relax.
_____   2. Insomnia or trouble sleeping.
_____   3. Difficulty making decisions.
_____   4. Serious life problems (including medical conditions or disability).
_____   5. Physical pain.
_____   6. Time-consuming, unproductive worry.
_____   7. Expecting the worst or thinking you can’t cope with things.
_____   8. Problems with anxiety or depression for many years (or all your life).
_____   9. Feeling depressed or not interested in your usual activities.
_____ 10. Phobias or fears.
_____ 11. Not being assertive enough.
_____ 12. Not having enough time to get things done.
_____ 13. Other: _______________________________________
_____ 14. Other: _______________________________________
_____ 15. Other: _______________________________________

evidence-based treatments for geriatric anxiety    35

 APPENDIX 2.4: Penn State Worry
Questionnaire (Abbreviated)

Rate each of the following statements on a scale of 1 (“not at all typical

of me”) to 5 (“very typical of me”). Please do not leave any items blank.

Not at all typical of me Very typical of me

Copyright American Psychological Association. Not for further distribution.

1 2 3 4 5
1. My worries overwhelm me. 1 2 3 4 5
2. Many situations make me worry. 1 2 3 4 5
3. I know I should not worry about things, but I just
cannot help it. 1 2 3 4 5
4. When I am under pressure I worry a lot. 1 2 3 4 5
5. I am always worrying about something 1 2 3 4 5
6. As soon as I finish one task, I start to worry
about everything else I have to do. 1 2 3 4 5
7. I have been a worrier all my life. 1 2 3 4 5
8. I notice that I have been worrying about things. 1 2 3 4 5

From “Development and Validation of the Penn State Worry Questionnaire,” by T. J. Meyer, M. L.
Miller, R. L. Metzger, and T. D. Borkovec, 1990, Behaviour Research and Therapy, 28, pp. 487–495.
Copyright 1990 by Elsevier. Reprinted with permission.

36    ghaed, ayers, and wetherell

 APPENDIX 2.5: Relaxation Script

As you settle into relaxation pose, relax the weight of your body into the
support of the floor. Notice how the body makes contact with the support of
the floor. Relax the back of your legs . . . the back of your hips . . . your lower
back, middle back and upper back. Relax the back of your shoulders . . . the
back of your arms . . . the back of your neck . . . and the back of your head.
Make any adjustments you need to, to relax the body into the ground more
fully. Relax into the support of floor, completely.
Copyright American Psychological Association. Not for further distribution.

Relax the muscles of your face. Relax your eyes and your forehead.
Relax your temples and cheeks. Relax you mouth and jaw. Relax your whole
face. Place your hands on your belly. Feel the rise and fall of your belly as you
breathe. Notice each inhalation as it enters the body, and each exhalation
as it exits the body. Let your breathing be soft, full and easy. No effort. Let
the body be breathed. As you inhale, say silently in your mind, “Let.” As you
exhale, silently say “Go.” Inhale, “Let.” Exhale, “Go.”
Continue to observe the breath, letting the body sink deeper and deeper
into relaxation. Let your arms rest by your side. As you exhale, make a soft
fist with each hand. As you inhale, relax the fist, and let your hands remain
softly curled and relaxed. Let the body sink deeper and deeper into the sup-
port of the floor.
Now, bring your awareness to your feet. Feel the soles of your feet, and
all 10 toes. Imagine that you could inhale and exhale through the soles of
your feet. Imagine the breath entering the body through the soles of the feet,
and exiting the body through the soles of the feet. Inhale. Exhale.
Now, bring your awareness to your hands. Feel the backs of the hands,
the palms of the hands and all 10 fingers. Imagine that you could inhale and
exhale through the palms of your hands. Imagine the breath entering the
body through the palms of your hands, and exiting the body through the
palms of your hands. Inhale. Exhale.
Now, bring your awareness to your belly. Feel the belly rise and fall as
you breathe. Imagine that you could inhale and exhale through the navel.
Imagine the breath entering the body through the navel and filling the belly.
Imagine the breath exiting the body through the navel. Inhale. Exhale.
Now, let your mind relax deeper, below awareness of the breath. Let
the mind relax below the level of concentration on anything, including the
breath. Let the body and mind let go. Let go, completely.

From Guided Relaxation Script: Breathing The Body, by IDEA Health & Fitness Association, 2012, San
Diego, CA: IDEA Health & Fitness, Inc. Retrieved from http://www.ideafit.com/fitness-library/guided-
relaxation-script-breathing-the-body. Copyright 2012 by IDEA Health & Fitness, Inc. Reprinted with
permission. Reproduction without permission is strictly prohibited. All rights reserved.

evidence-based treatments for geriatric anxiety    37

 [Let students or client relax. When you are ready, continue.]
Notice your breathing. Notice each inhalation as it enters the body and
each exhalation as it exits the body. Bring your hands back to the belly, and
feel the belly rise and fall. Let your breathing be soft, full and easy. Notice the
whole body. Notice the whole body supported by the floor. Notice how easy
it is to be in your body, in this moment. Feeling fully supported, in this pose,
and in all areas of your life.
When you’re ready to begin moving out of relaxation, gently move the
fingers and toes. Let some sensation spread into the hands and feet. Stretch
Copyright American Psychological Association. Not for further distribution.

or move in any way that feels good. Then roll onto your right side, and rest
there. Breathe easily. Take the best feeling of this relaxation with you.

38    ghaed, ayers, and wetherell

 APPENDIX 2.6: SOLVE Worksheet

Anxiety (circle a number):

0 1 2 3 4 5 6 7 8 9 10
None Mild Moderate Strong Extreme

Symptoms:
[ ] Worried, nervous, or fearful
Copyright American Psychological Association. Not for further distribution.

[ ] Restlessness/keyed up/on edge

[ ] Fatigue
[ ] Difficulty concentrating
[ ] Irritability
[ ] Muscle tension
[ ] Trouble sleeping
[ ] Pounding or racing heart
[ ] Shortness of breath
[ ] Trembling or shaking
[ ] Nausea/diarrhea/upset stomach
[ ] Numbness or tingling
[ ] Faintness or dizzy spells
[ ] Hot or cold flashes

Use the “SOLVE” technique:

Specific problem:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Outline all possible solutions:

_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

List the advantages and disadvantages of the two best solutions:

_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Visualize a plan for the best solution, including resources and date:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

evidence-based treatments for geriatric anxiety    39

 Evaluate the results: Do it and see how it worked.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Copyright American Psychological Association. Not for further distribution.

40    ghaed, ayers, and wetherell

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