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Generalized Anxiety Disorder
Lauren E. Szkodny and Michelle G. Newman
Pennsylvania State University, United States

Therapists and clinical scientists involved in the study, assessment, and treatment of
generalized anxiety disorder (GAD) undoubtedly encounter individuals preoccupied
with intense and pervasive worry and anxiety. Whereas worry is a universal experience,
common in both nonpathological and anxious populations, individuals with GAD
stand apart, as their worry is more pervasive and less controllable, thereby engendering
greater distress and life interference. Typically describing themselves as lifelong
worriers, these individuals perceive their worrisome thinking and associated anxiety as
facets of their personality, enduring traits rather than phenomena prone to fluctuations
that can be monitored, targeted, and effectively changed. In fact, worry may be viewed
as such a central part of life, a primary coping strategy used to avoid perceived threat
and changes in emotional reactivity, that treatment may not even be considered
(Newman, Crits-Christoph, & Szkodny, in press).
GAD has been referred to as the “basic” anxiety disorder (Brown, Barlow, &
Liebowitz, 1994), an appellation that suggests understanding the development and
maintenance of GAD is important for understanding all anxiety disorders. Given
GAD’s course and documented resistance to change, research has centered not
only on elucidating the nature and etiology of this disorder, but also on developing
treatments that improve upon standard versions of cognitive behavioral therapy
(CBT). This has been most critical since worry is a means to avoid anticipated threats,
as opposed to tangible, anxiety-provoking stimuli, and thus is not as easily addressed
with exposure interventions commonly executed in the treatment of other anxiety
disorders (Newman & Borkovec, 2002). The principal objective of this chapter is to
present an overview of CBT for GAD. First, the symptomatology of GAD is discussed,
followed by a presentation of the cognitive behavioral treatment rationale and CBT
techniques. Additionally, empirical evidence supporting the efficacy of CBT for GAD

The Wiley Handbook of Cognitive Behavioral Therapy, First Edition.

Edited by Stefan G. Hofmann. Volume III edited by Jasper Smits.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.
DOI: 10.1002/9781118528563.wbcbt42
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is reviewed. This chapter also discusses the limitations of CBT methods and presents
a number of integrative techniques that have been incorporated into CBT for GAD.

Phenomenology of Generalized Anxiety Disorder

The Diagnostic and statistical manual of mental disorders (DSM-IV-TR; American

Psychiatric Association [APA], 2000) indicates that excessive and uncontrollable
worry, defined as apprehensive expectation, is the core feature of GAD. To meet
criteria, individuals must experience worry more days than not for at least 6 months
about a number of events or activities. Additionally, their worry and anxiety is
generally associated with at least three of the following six physical symptoms: (a)
restlessness or feeling keyed up or on edge, (b) being easily fatigued, (c) difficulty
concentrating or mind going blank, (d) irritability, (e) muscle tension, and (f) sleep
disturbance characterized by difficulty falling or staying asleep, or restless, unsatisfying
sleep. Finally, their worry and anxiety must (a) not be confined to features of an
Axis I disorder (e.g., worry about having a panic attack [panic disorder] or being
embarrassed in public [social phobia]), (b) cause clinically significant distress or
impairment in important domains of functioning, and (c) not be due to the direct
physiological effects of a substance or a general medical condition.
GAD symptoms have undergone extensive empirical revision since its inception in
the DSM-III (APA, 1980) as a residual category (Brown et al., 1994). In the DSM-
III-R revision, the pervasiveness and uncontrollability of worry were emphasized, but
the unrealistic nature of worry was dropped from the definition.
Following an investigation of the reliability and frequency of the endorsement of
the 18 associated features (somatic symptoms) delineated in the DSM-III-R (Marten
et al., 1993), autonomic hyperactivity symptoms (e.g., sweating, dry mouth) were
identified as the least reliable and least frequently endorsed among individuals with
GAD. The six symptoms indicated in the DSM-IV-TR (APA, 2000) were identified
as the symptoms that significantly discriminated patients with GAD from individuals
diagnosed with other anxiety disorders (Brown, Marten, & Barlow, 1995). Members
of the GAD work group for the DSM-5 propose to remove the criterion related to
the difficulty of controlling worry given its overlap with the excessiveness criterion,
to reduce GAD’s threshold to 3 months (as opposed to 6 months), to change the
number of physical symptoms required from three to one, and to add a criterion that
taps into situational avoidance, excessive effort toward preparation, procrastination,
and reassurance seeking.
Contrary to the notion that GAD is a reflection of a highly functioning diagnostic
group (e.g., the worried well), or that GAD is only impairing as a result of its high
degree of comorbidity with other disorders, the degree of disability in persons with
pure GAD (without comorbidity) is as severe as pure major depressive disorder (MDD)
and other mood disorders (Hoffman, Dukes, & Wittchen, 2008). Also, incapacity
as a result of GAD is analogous to that seen in chronic medical illnesses (Ansseau
et al., 2008; Fifer et al., 1994; Stein, 2001). GAD is also more debilitating than
pure alcohol and drug use disorders, nicotine dependence, other anxiety disorders,
and personality disorders even when sociodemographic and all other co-occurring
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disorders are controlled (Grant et al., 2005). Persons with GAD are among the most
frequent consumers of primary care, specialty clinic, and emergency room services,
incurring significant nonpsychiatric cost (Fogarty, Sharma, Chetty, & Culpepper,
2008; Mehl-Madrona, 2008). GAD is also a major risk factor for coronary heart
disease independent of depression (Barger & Sydeman, 2005; Todaro, Shen, Raffa,
Tilkemeier, & Niaura, 2007). The direct excess yearly cost of GAD has been estimated
to be as high as $20,184 per case (Olfson & Gameroff, 2007). Therefore, untreated
GAD is very costly in terms of distress, disability, lost work productivity, quality of
life, and medical problems (Newman, 2000).
Worry has been defined as “a chain of thoughts and images, negatively affect-laden
and relatively uncontrollable; it represents an attempt to engage in mental problem-
solving on an issue whose outcome is uncertain but contains the possibility of one
or more negative outcomes; consequently, worry relates closely to the fear process”
(Borkovec, Robinson, Pruzinsky, & DePree, 1983, p. 10). Individuals with GAD are
generally apprehensive about the occurrence of negative future outcomes related to
major life issues (e.g., family and interpersonal relationships, finances, health, occupa-
tional and academic pursuits) and minor concerns (e.g., household repairs or chores)
(Borkovec, Ray, & Stober, 1998). Pathological worry comprises a spiraling chain of
cognitive, behavioral, and physiological events (Newman & Borkovec, 2002) trig-
gered by a perceived stressor, especially one characterized by ambiguity or uncertainty.
To illustrate, in response to an ambiguous comment made by a romantic partner, an
individual with GAD would likely experience an anxious thought (e.g., “He is angry
with me”) and associated physiological response (e.g., increased tension, which may
interfere with falling asleep), to be followed by another worrisome thought (e.g., “He
is going to break up with me) and elicited negative emotion (e.g., anxiety, despair),
which might activate more anxious thoughts related to a core negative belief (e.g.,
‘‘I’m unlovable and will be alone forever”). This cycle is often difficult to break as
one worry leads to another and so on to the point that it becomes disabling and
is a source of extreme emotional discomfort, so cognitive behavioral techniques are
implemented to teach clients to identify initial anxiety cues to reduce the intensity of
the worry/anxiety spiral (Newman & Borkovec, 2002).
Additionally, individuals with GAD exhibit an information processing bias; they
scan their surrounding environment for potential danger, and negatively interpret
ambiguous or neutral stimuli, thereby detecting threat in them (Mathews, 1990;
Mathews & MacLeod, 1994). In perceiving the world as a dangerous place, their
anticipation of negative outcomes or worst-case scenarios seemingly enhances their
sense of control, such that worry represents mental attempts at avoidance of threat or
preparation for its occurrence if it cannot be avoided (Borkovec et al., 1998; Borkovec,
Alcaine, & Behar, 2004). Nevertheless, worry’s avoidant function precludes repeated
exposure to those stimuli necessary for extinction, thus preserving anxious meaning
associated with the threat (Newman & Llera, 2011). Specifically, it diminishes initial
cardiovascular response to threatening images and reduces the likelihood of additional
affective reactivity subsequent to an anxiety-provoking event or situation (Borkovec
& Hu, 1990; Llera & Newman, 2010; Newman & Llera, 2011), which impedes
emotional processing of aversive stimuli.
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Although worry is associated with increased anxiety and distress, it is maintained by

positive beliefs regarding its functionality. For instance, individuals with GAD have
indicated that worry helps them to determine ways to avoid negative events, prepare
for the occurrence of negative outcomes, problem solve, and retain motivation
(Borkovec & Roemer, 1995). Likewise, worry is inherently reinforcing since the
feared negative outcomes rarely, if ever, occur (Borkovec, Hazlett-Stevens, & Diaz,
1999). Over time, worry, the nonoccurrence of the feared event, and subsequent
reduction in anxiety become inextricably linked, in the absence of intervention.
Therefore, treatment for GAD has involved identification of those factors maintaining
worry, especially since positive perceived benefits of worrisome thinking can interfere
with individuals’ willingness to commit to treatment and engage in interventions
designed to reduce their worry.
GAD is a prevalent and highly comorbid and chronic psychiatric disorder that is
associated with fluctuations in symptom severity and impairment (Wittchen, Lieb,
Pfister, & Schuster, 2000; Yonkers, Warshaw, Massion, & Keller, 1996) that are
not necessarily indicative of recovery (Newman et al., in press). Epidemiological
studies revealed lifetime prevalence of DSM-III-R GAD from 3.6 to 5.1% (Wittchen,
Zhao, Kessler, & Eaton, 1994) and 5.7% for DSM-IV GAD (Kessler et al., 2005).
GAD comorbidity rates are high in both clinical and community samples; major
depressive disorder, followed by panic disorder, social phobia, and dysthymia, are
the four most common comorbid Axis I anxiety and mood disorders, respectively
(Brown & Barlow, 1992; Massion, Warshaw, & Keller, 1993). Additionally, avoidant
and dependent personality disorders have been found to be the two most common
comorbid Axis II diagnoses for GAD (Sanderson & Wetzler, 1991; Sanderson,
Wetzler, Beck, & Betz, 1994). The gravity of this disorder is not only captured by its
extensive comorbidity, but by its course as well. GAD is a chronic illness characterized
by a later onset than other anxiety disorders (Berger et al., 2011; Kessler et al., 2005),
low probability of recovery, and high likelihood of recurrence (Newman et al., in
press). Naturalistic prospective studies of psychiatric and primary care patients found
a 32 to 58% probability of recovery in GAD over a 2- to 12-year period, and a 45 to
52% recurrence in individuals who did not recover (Rodriguez et al., 2006; Yonkers,
Dyck, Warshaw, & Keller, 2000).

Cognitive Behavioral Therapy for

Generalized Anxiety Disorder

The uncontrollability and pervasiveness of worry central to GAD, its degree of comor-
bidity and chronic course, and its associated psychosocial impairment underscore the
need for highly effective GAD treatments. GAD symptoms have been conceptu-
alized as an interaction between the cognitive, affective, imaginal, behavioral, and
somatic responses to perceived future threat (Holmes & Newman, 2006; Newman
& Borkovec, 2002). Thus, CBT packages attempt to target each of those response
systems. Traditional cognitive behavioral interventions include self-monitoring, relax-
ation techniques, stimulus control, self-control desensitization, and cognitive therapy,
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and reflect five principles of change: (a) challenging misconceptions, (b) actively test-
ing the validity of erroneous beliefs, (c) using repeated exposure methods, (d) reducing
avoidance behaviors, and (e) improving skills (Newman, Stiles, Janeck, & Woody,
2006). The efficacy of these methods has been documented in a series of randomized
controlled trials (RCTs); however, GAD symptoms do not appear to remit at the same
rate as those of other anxiety disorders (Yonkers, Bruce, Dyck, & Keller, 2003), so
research centered on enhancing understanding of the etiology, maintenance, and treat-
ment of GAD has continued. Therapeutic advancement for GAD has been made in the
areas of interpersonal and emotional processing therapy, emotional contrast exposure
therapy, metacognitive therapy, treatment of intolerance of uncertainty, integration of
acceptance and mindfulness techniques with CBT, and emotion regulation therapy.

A Cognitive Behavioral Approach to Psychopathology and Treatment

Cognitive behavioral theory posits that forms of psychopathology are due to mal-
adaptive patterns of thoughts and behaviors (e.g., Beck, 2005). Symptoms arise from
modeling negative coping behaviors, classical and operant conditioning processes,
and core beliefs that influence maladaptive responses to stressful events. Individuals
with emotional disorders have biased schemata, perceiving situations in terms of
loss, danger, or other types of threat to the self. Specifically, individuals with GAD
interpret ambiguous or neutral information in a negative light. They are convinced
that by anticipating the worst-case scenario, they will be prepared in the event of
a negative outcome. Their worry becomes such a consuming, cyclical process that
they are unable to incorporate all information available in their environment to func-
tion effectively. Instead, they are biased toward negative information and/or distort
situations to fit their beliefs, which interferes with adaptively coping with stressful
situations (Borkovec, 2002).
In anxiety-provoking and perceived threatening situations, the instinctive maneuver
is to attempt to prepare for a threatening outcome via worry, which may serve
a self-sustaining function, until it becomes habitual. Individuals’ life functioning
becomes more restricted; they do fewer things and see fewer people, all in the
interest of circumventing potential threat (Wittchen, 2002). Therefore, CBT targets
this process, and encourages individuals to confront and challenge their fears. The
goal of therapy is not to eliminate worry and anxiety altogether, but to reduce them
in manageable increments while enhancing individuals’ ability to cope and function
in spite of some anxiety. A cognitive behavioral treatment framework focuses on the
acquisition of skills to manage worry and anxiety. Clients learn to slow down their
breathing, reduce chronic bodily tension, and challenge and change their negative
thinking patterns. As with most CBT, these skills are developed through the use of
in- and between-session practices. Ultimately, CBT emphasizes identification of early
anxiety triggers, the disruption of factors maintaining worry, and the development
of more adaptive ways of thinking and behaving in the face of ambiguous situations.

Psychoeducation. Initial therapy sessions center on teaching clients about the nature
of their worry and anxiety, as well as factors that can contribute to the maintenance of
GAD. An overview of treatment components and rationale is also typically provided.
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Self-monitoring/early cue detection. As indicated, an objective of CBT is to interrupt

factors maintaining worry and anxiety. Before therapist and client can intervene,
it is important to know what those factors are and when and where they occur.
Such identification is facilitated by ongoing daily self-monitoring, which helps to
increase patients’ awareness of maladaptive and habitual cognitive, behavioral, and
physiological patterns of responding. The more adept clients become at identifying
early automatic processes or triggers for their symptoms, the more efficient they
can become in engaging adaptive and strategic behaviors to overcome maladaptive
response biases. The primary functions of self-monitoring are to increase clients’
awareness of their early worry and anxiety triggers and how they behave in response
to those triggers and enhance recognition of shifts in their internal state (Borkovec,
2006). By learning to detect worry cues as soon as they occur, clients will be able
to intervene by deploying coping strategies early on in the worry/anxiety spiral. This
process is considered crucial to successful treatment.
Furthermore, self-monitoring also enables individuals with GAD to focus on the
present moment. Since they are preoccupied with the anticipation of negative events
or the future implications of past stressors, their anxiety is predominantly generated
by their biased thoughts and images (Borkovec, 2006). Thus, individuals with GAD
tend to be distracted from what is happening in the moment and instead tend to live
their lives in the future. Monitoring internal and external anxiety triggers encourages
clients to become more grounded in the present moment and to make use of all
information available to them in their environment. Through monitoring, clients learn
to draw in-the-moment connections between their anxious responses and negatively
biased interpretations, thereby creating opportunities for intervention and application
of more flexible, present-focused thinking.
Self-monitoring is practiced both in and out of session through the use of several
tracking techniques. Clients typically engage in this process by first keeping a daily
record of their anxiety levels and associated thoughts, feelings, and behaviors at
regular intervals throughout the day (e.g., morning, afternoon, evening, before going
to bed). Clients may also monitor their anxiety on an hourly basis or with every
change in activity (Newman & Borkovec, 2002). This repeated monitoring may help
them better understand the mechanisms that are operating to trigger their worry.
Additionally, they learn to identify different manifestations of their anxiety, such as
their thoughts, behaviors, and affect, that interact to exacerbate their distress and
impair functioning. As distorted and biased cognitions are likely to contribute to
anticipatory anxiety, ongoing self-monitoring facilitates more accurate assessment
and interpretation of worry and anxiety. Daily records also allow for observing and
tracking changes in anxious thoughts, feelings, and bodily sensations, as well as other
negative emotions, such as depression, anger, and shame (Newman & Borkovec,
2002) over time. These diaries may be used to monitor intraindividual variation in
symptoms (Fisher, Newman, & Molenaar, 2011) and functioning and therapeutic
progress, and evaluate clients’ degree of success in applying more effective coping
strategies. Therapist and client may also use them to generate dialogue about the
causal relationships between internal and external cue, symptom, and distress.
Additionally, the therapist may have clients imagine themselves in (or describe past
instances of) stressful, worrisome, or anxiety-provoking situations with the aim of
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focusing on their thought processes, behaviors, and emotions. Having clients silently
engage in a period of worry and describe their sequence of cognitive, affective, and
somatic reactions, as their anxiety and worry processes develop, may also facilitate
observation of worry and anxiety. During this exercise, the therapist also monitors
shifts in clients’ verbal and nonverbal behaviors that signal anxiety, and halts clients’
worry episodes to inquire whether they noticed their reaction and can identify the
internal cues that may have triggered the nonverbal behavior (Borkovec, 2006;
Newman & Borkovec, 2002). Between session, clients may also be instructed to track
their worry episodes, including information initial cues, worry content including feared
outcome, amount of time spent worrying, highest anxiety level, actual outcome, and
how well they coped with the outcome (Newman & Borkovec, 2002). The ultimate
goal of self-monitoring is to learn to identify early triggers for and signs of worry,
before such worry becomes too intense to intervene. The sooner the client intervenes
in response to a worry trigger, the more effective the intervention is theorized to
be. If clients wait until their worry has become more intense or until later in the
worry cycle, it is virtually impossible to cut it off successfully. Thus clients are asked
to objectively observe earlier and earlier shifts in anxiety and associated internal and
external responses, and immediately apply effective coping strategies to remediate
patterns of habitual and maladaptive functioning.

Relaxation training. Individuals with GAD exhibit a distinctive psychophysiological

profile relative to other anxiety disorders. GAD has been associated with chronic
vigilance to threat and scanning, and, in some individuals, excessive muscle tension
(Hoehn-Saric & McLeod, 1988; Lyonfields, Borkovec, & Thayer, 1995). Individuals
with GAD do not demonstrate typical cardiac reactivity in response to threat observed
in those diagnosed with other anxiety disorders. Rather, they show a reduction in the
range of heart rate variability, or vagal tone, indicative of autonomic rigidity (e.g.,
lack of autonomic reactivity) (Hoehn-Saric & McLeod, 1988; Thayer, Friedman,
& Borkovec, 1996). Experimental studies have demonstrated that inducing worry
states reduces vagal tone (Llera & Newman, 2010; Thayer & Borkovec, 1995),
suggesting that pervasive worry is related to the vagal deficit and autonomic rigidity
found in GAD (Holmes & Newman, 2006). Such a vagal deficit is indicative of high
chronic heart rate and sustained chronic levels of negative emotionality (Newman &
Llera, 2011). Accordingly, various relaxation techniques have been incorporated in
the treatment of GAD to increase autonomic flexibility. Relaxation methods include
diaphragmatic breathing, progressive muscle relaxation, pleasant imagery, meditation,
and applied relaxation. These strategies assist clients in slowing down their breathing,
differentiating between feelings of tension and relaxation, and enhancing flexibility of
responding.
Slowed, paced diaphragmatic breathing is a relaxation technique that induces a
rapid relaxation response (Newman & Borkovec, 2002). Clients are first taught
that anxiety is associated with rapid breathing originating in the chest rather than
the diaphragm. Whereas chest breathing activates the sympathetic nervous system,
which is implicated in the fight-or-flight response to perceived threat, diaphragmatic
breathing stimulates the parasympathetic nervous system, which is responsible for
“rest and digest” activities. Clients learn to distinguish between these two types of
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breathing by first simulating rapid chest breathing until they induce anxiety, and
then engaging in slow-paced, diaphragmatic breathing to reduce their anxiety. The
therapist should encourage clients to practice this slowed breathing exercise during
and between sessions, and apply it in response to anxiety cues. In sum, clients learn
about how their breathing affects how they feel and monitor and alter their breathing
habits with the goal of gaining more control over their physiological and emotional
responding (Newman & Borkovec, 2002).
Progressive muscle relaxation (PMR; Bernstein, Borkovec, & Hazlett-Stevens,
2000) is another useful relaxation method that can benefit individuals with GAD.
PMR involves the systematic tensing and releasing of different groups of muscles
of the body, as well as focusing on subsequent relaxing bodily sensations. In our
approach, relaxation practice occurs as a component of virtually every therapy session.
Clients begin by tensing and releasing 16 separate muscle groups, including the right
hand and forearm, right biceps, left hand and forearm, left biceps, forehead (upper
face), eyes and nose (central face), mouth, jaws, and cheeks (lower face), neck, chest,
shoulders and upper back, abdomen, right thigh, right calf, right foot, left thigh,
left calf, and left foot. As sessions progress, muscle groups are combined to enhance
the efficiency of the method (e.g., producing a more relaxed state in less time)
(Borkovec, 2006). Over time, clients are effectively able to engage in “relaxation by
recall,” or relax their muscles in the absence of tensing them. This is achieved through
remembering the feeling produced by repeated tension and release of their muscles
(Borkovec, 2006; Newman & Borkovec, 2002). During this procedure, clients learn
to pair PMR with the “letting go” of their anxiety and troublesome emotions. They
are taught to release their worrisome thoughts and images, and instead focus on
their breathing and sensations of relaxation. Eventually, clients are taught “recall and
counting,” a technique where they sequentially focus on various muscle groups and
relax away tension while counting to 10. Ultimately clients learn to relax by counting
alone. They engage in these relaxation exercises while simultaneously attempting
regular applied relaxation wherein they regularly scan their bodies and in the moment
attempt to release any tension.
Diaphragmatic breathing and PMR may be supplemented through the use of
pleasant imagery or meditation techniques. Imagery relaxation involves vividly creating
a scene that is associated with feelings of relaxation, peace, comfort, and tranquility.
Guided pleasant imagery, a method in which the therapist and client collaborate in
constructing a peaceful mental scenario, can be used in therapy to achieve deeper states
of relaxation. A useful associated meditational technique involves the incorporation of
a specific cue, such as repeating the word “calm” to oneself. Clients can use this device
to refocus their attention when they notice their minds wandering or infiltration of
cognitive intrusions (Borkovec, 2006; Newman & Borkovec, 2002). Likewise, clients
are taught to engage in applied relaxation (Öst, 1987). In other words, they are
encouraged to utilize their relaxation skills in response to internal and external signs
of anxiety or shifts in emotional and/or physiological responding identified during
self-monitoring in order to release their tension.
Overall, relaxation techniques are used in the context of therapy for GAD to
enhance clients’ focus on the present moment, eliminate unnecessary bodily tension,
and decrease the frequency of worry episodes. This enables them to incorporate new
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information from their environment to facilitate adaptive learning and behavior. The
availability of different relaxation techniques can be especially beneficial for clients who
experience relaxation-induced anxiety (RIA; Heide & Borkovec, 1984). Although
they may experience increased discomfort or a fear of losing control in response to
the enhanced awareness of emotional responding attributed to a specific relaxation
technique, continued relaxation practice helps them overcome this feeling (Heide &
Borkovec, 1983; Newman & Borkovec, 2002). Thus, relaxation training aims to help
clients gain control over their worry and anxiety.

Imaginal rehearsal of coping skills. The treatment of GAD less frequently incorporates
the use of traditional exposure methods often used in targeting phobias since the fear
resides in the mind of the individual with GAD. Conversely, imaginal rehearsal of the
execution of coping skills allows for repeated practice of adaptive coping strategies
and enhanced self-efficacy. Specifically, self-control desensitization (Goldfried, 1971)
makes use of imagery after the induction of a deeply relaxed state through the use of
PMR. Initially, a client creates a hierarchy of worry triggers that are graded from least
to most anxiety-provoking. Then the therapist selects a trigger from the hierarchy
and works with the client to come up with a prototypical scenario wherein the
trigger might occur for him or her. Next the client undergoes progressive muscle
relaxation. Once relaxed, the therapist presents an image that comprises both internal
and external anxiety cues relevant to the client’s daily emotional experience. The
client imagines him- or herself in the scene and signals to the therapist with his or
her finger once anxiety is experienced. The client then applies relaxation techniques
and practices replacing anxiety-provoking thoughts with more adaptive, accurate
perspectives formed during the cognitive therapy portions of therapy (Borkovec,
2006). The client then indicates when there is a decrease in his or her anxiety while
still envisioning the image by lowering his or her finger. Once the client has had the
opportunity to experience successful coping in response to the worrisome scene for
a period of time (about 20 seconds), he or she is instructed to “turn off” the scene
and deepen his or her state of relaxation (about 20 seconds) (Borkovec, 2006). This
technique is repeatedly practiced until the coping strategies become more habitual.
The implementation of self-control desensitization involves both applied relaxation
and coping strategies. By imagining worrisome scenarios and picturing themselves
in a place of enhanced flexibility of responding, clients are in a position more
readily to apply these skills in daily life, thereby enhancing their self-efficacy and
adaptive decision-making ability. Therefore, it is important for clients to monitor
their worry and anxiety consistently and to strengthen their adaptive coping skills
through continued practice.

Cognitive therapy. Cognitive therapy is warranted given the hypervigilance toward

threat cues (Mathews, 1990; Mathews & MacLeod, 1994) observed in GAD. It
is based on the premise that emotional responding is influenced by individuals’
interpretation of specific stimuli (e.g., bodily sensations, external stressors). Individuals
with GAD commonly misjudge the likelihood of feared events. Thus cognitive therapy
is used to address worry and catastrophic thinking and other cognitive and perceptual
inaccuracies through a number of steps: (a) monitoring and detecting clients’ way of
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perceiving themselves and the world, (b) identifying inaccurate and anxiety-provoking
thoughts and cognitive errors, (c) challenging these cognitions through examination
of logic and evidence for the accuracy or inaccuracy of these thoughts, (d) generating
alternative, more accurate perspectives and beliefs, (e) applying more accurate, logical,
and adaptive ways of thinking in daily life when worry and anxiety are detected, and
(f) conducting experiments in daily life to provide support for using more flexible
thinking.
Cognitive restructuring is a useful and effective tool in challenging individuals’
worrisome thoughts. Clients first and foremost learn to recognize their thoughts as
hypotheses, rather than facts, and are encouraged to gather and examine confirming
and disconfirming evidence and avoid common errors, such as confusing thought with
action or thought with fact. This is especially important as individuals’ perceptions and
judgments are likely to be distorted by their emotional reactivity. To illustrate, high
anxiety can result in particular biases where individuals overestimate the likelihood of a
risk or threat (i.e., assuming that negative outcomes are more probable than actuality)
or magnify the valence of negative events (i.e., inflating the meaning of an event
or perceiving it as unmanageable), and whereas these biases can serve a protective
function in response to real threat, they can exacerbate worry and anxiety in the
absence of tangible danger. Thus, cognitive restructuring functions as a management
strategy to correct misinformation and misinterpretations of perceived threat. By
focusing on errors in logic and generating different ways to approach a situation,
clients can learn to countermand their negative automatic thoughts and beliefs.
Overall, cognitive therapy and its related techniques enable clients to reinterpret
stimuli in a more accurate, positive light based on the reality of their environment.
One important focus of cognitive restructuring in persons with GAD is their view
that worry helps them (e.g., Borkovec & Roemer, 1995). Such a perspective can be
an initial roadblock to the success of garnering their cooperation in reducing their
worry. Thus, cognitive therapy often includes behavioral experiments wherein clients
can gather evidence for and against the helpfulness or lack thereof of worry and can
ultimately feel comfortable working with therapists to reduce their worry.

Targeting intolerance of uncertainty. A cognitive model of worry centered on intol-

erance of uncertainty (IU) stipulates that individuals with GAD are characterized
by heightened sensitivity to ambiguous and uncertainty-relevant information (Dugas,
Buhr, & Ladouceur, 2004). IU affects how individuals perceive, interpret, and respond
to situations marked by uncertainty on cognitive, emotional, and behavioral levels,
and is theorized to contribute to the development and maintenance of excessive and
uncontrollable worry in two ways: (a) operation of cognitive biases (direct link with
worry) and (b) facilitation of worry via the processes of positive beliefs about worry,
negative problem orientation, and cognitive avoidance (indirect link with worry)
(Koerner & Dugas, 2006).
Individual and group cognitive behavioral treatment packages have been designed
and implemented to address the four processes implicated in the development and
maintenance of GAD. These processes are intolerance of uncertainty, positive beliefs
about worry, negative problem orientation, and cognitive avoidance (Dugas et al.,
2003; Ladouceur et al., 2000). The principal treatment components include (a)
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psychoeducation about CBT and GAD/worry, (b) worry awareness training, (c)
coping with uncertainty, (d) reevaluating beliefs about the usefulness of worry, (e)
improving problem orientation and problem-solving ability, (f) processing core fears
through imaginal exposure, and (g) relapse prevention (Robichaud & Dugas, 2006).

Targeting metacognitive appraisals, beliefs, and strategies. A metacognitive model of

pathological worry and GAD distinguishes between worry (Type 1 worry) and negative
interpretations of worry (Type 2 worry or “meta-worry”) (Wells, 1994). Type 2 worry
captures the negative metacognitive appraisal of worry as dangerous or uncontrollable,
which is implicated in the development of GAD. Conversely, Type 1 worry is triggered
by the positive beliefs people have about worry (e.g., “I can avoid future failure if
I worry about all possibilities”), and is therefore typically employed as a coping
strategy. However, worry can impede more adaptive self-regulatory mechanisms,
thereby activating negative metacognitive beliefs and associated meta-worry (Wells,
2006b).
The primary objectives of metacognitive therapy (MCT) for worry and GAD are to
identify and modify metacognitive appraisals and beliefs about worry and foster a flex-
ible coping approach through use of alternative, more adaptive strategies to deal with
worry triggers (Wells, 2006a). MCT includes individualized case conceptualization;
socialization, or psychoeducation about the nature and structure of the treatment
and the role of worry-related metacognitions; modification of metacognitions related
to the uncontrollability and danger of worry; modification of positive metacognitive
beliefs; and relapse prevention (Wells, 1997, 2006a).

Cognitive bias modification. Individuals with GAD exhibit an attention bias toward
threat (Mathews & MacLeod, 1994), which has been experimentally examined
using the probe detection paradigm (see Mogg & Bradley, 2005, for a review).
Accordingly, an attention modification program (AMP) has been implemented to
decrease attention to threat and anxiety (Amir, Beard, Burns, & Bomyea, 2009). This
computer-administered program involves various combinations of probe type, probe
position, and word type (neutral or threat) and aims to shift individuals’ attention bias
toward threat, thereby reducing symptoms of anxiety. In comparison to an attention
control condition, the AMP significantly modified attention bias toward threat and
reduced self-reported anxiety symptoms (Amir et al., 2009).

Efficacy of Cognitive Behavioral Therapy for

Generalized Anxiety Disorder

Controlled investigations of the efficacy of CBT and related techniques in treating

GAD have been conducted within the last several decades. Whereas outcome studies
for other anxiety disorders primarily examined the effectiveness of exposure-based
cognitive behavioral interventions, the efficacy of relaxation, imaginal, and cognitive
techniques in treating GAD was evaluated (Newman & Borkovec, 2002). Early clin-
ical trials investigated the treatment of “general anxiety,” a non-DSM category, and
found that combined anxiety management treatments resulted in prolonged symptom
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improvement, which sometimes surpassed the effects of individual components

(Newman & Borkovec, 2002). Cognitive therapy interventions were also found
to improve symptoms (Durham & Turvey, 1987; Newman & Borkovec, 2002).
Borkovec and Ruscio (2001) conducted a meta-analysis of 13 controlled clinical
trials examining the efficacy of CBT for GAD, and found highly consistent outcomes.
Importantly, the methodological rigor of the reviewed studies enhances the reliability
and validity of study results. For example, (a) studies selected participants based on
their meeting DSM diagnostic criteria for GAD; (b) most studies incorporated the use
of detailed treatment protocols (n = 9) and conducted adherence checks (n = 8); (c)
some studies assessed nonspecific factors (e.g., the client’s belief in the appropriateness
of the treatment, therapy expectancy) to determine equivalency of conditions (n = 8);
(d) all investigations included follow-up assessments 6 or 12 months posttreatment;
and (e) overall attrition was low in all controlled trials.
This meta-analysis revealed that CBT significantly reduced anxious and depres-
sive symptoms over the course of treatment with an average effect size of 2.48 at
posttreatment and 2.44 at follow-up for anxious symptoms, and 1.13 at posttreat-
ment and 1.22 at follow-up for depression measures, thereby capturing therapeutic
gains in anxious and depressive symptoms. Placebo or alternative psychotherapies
(e.g., nonmanualized psychodynamic psychotherapy, two trials incorporating low
doses of diazepam) resulted in the next highest effect sizes on worry, anxiety, and
depression measures followed by individual CBT components (i.e., behavior therapy
or cognitive therapy), and wait-list/no-treatment conditions. In an examination of
therapeutic efficacy, CBT yielded the greatest reduction of anxious and depressive
symptoms (greatest effect sizes) at posttreatment and follow-up compared to the
other conditions. Between-group comparisons demonstrated that CBT was superior
to wait-list/no-treatment at posttreatment with an average effect size of 1.09 and
0.92 for anxiety and depression measures, respectively. CBT also exhibited greater
efficacy than nonspecific or alternative therapies, with an average effect size for anxiety
and depression measures, respectively, of 0.71 and 0.66 at posttreatment and 0.30
and 0.21 at follow-up; and cognitive or behavioral treatment alone, with an average
effect size of 0.26 for both anxiety and depression measures at posttreatment and
0.54 and 0.45 for anxiety and depression measures, respectively, at follow-up.

Toward Therapeutic Integration

Although CBT for GAD consistently results in significant reductions in anxiety and
mood symptoms, gains that are often maintained at follow-up, GAD still remains
the least successfully treated anxiety disorder (Brown et al., 1994). Approximately
50% of individuals achieve high end-state functioning (range from 40 to 60%) at 6-
and 12-month follow-up (Borkovec & Costello, 1993; Borkovec, Newman, Pincus,
& Lytle, 2002; Borkovec & Whisman, 1996; Dugas et al., 2003; Ladouceur et al.,
2000; Wells et al., 2010), suggesting the need for enhancements to the current CBT
model. Whereas CBT protocols typically adhere to a prescribed number of treatment
sessions, Borkovec et al. (2002) addressed the potential need for additional CBT
sessions to receive maximum benefit by significantly increasing the amount of client
contact time from a previous study (Borkovec & Costello, 1993). However, the rate
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Generalized Anxiety Disorder 1013

of high end-state functioning did not increase, although contact time had doubled.
Another consideration regarded CBT’s lack of focus on critical factors contributing
to the maintenance and development of GAD. Accordingly, treatment for GAD has
been supplemented with additional techniques designed to address aspects of GAD
not commonly targeted in traditional CBT (e.g., interpersonal dysfunction, emotional
processing, emotional dysregulation) in an effort to improve its efficacy.

Integration of interpersonal/experiential therapy. GAD is marked by significant inter-

personal dysfunction and avoidance of emotional processing (Borkovec et al., 2002;
Newman & Erickson, 2010; Przeworski et al., 2011). In terms of interpersonal
problems, it is associated with more marital discord or dissatisfaction than other
anxiety or mood disorders, and distortions in perceptions of negative interpersonal
impact on others (Erickson & Newman, 2007; Newman et al., in press). These inter-
personal factors predict negative CBT outcomes, higher dropout rates, and reduced
probability of remission (Durham, Allan, & Hackett, 1997; Newman et al., in press).
With respect to difficulties with emotion, worry inhibits cardiovascular response to
fearful stimuli (Borkovec & Hu, 1990; Llera & Newman, 2010; Newman & Llera,
2011), thereby diminishing processing of negative emotions. Individuals with GAD
also report greater sensitivity to their negative emotions (Llera & Newman, 2010;
Mennin, Heimberg, Turk, & Fresco, 2005), increased emotional intensity (Mennin
et al., 2005), and heightened reactivity to negative emotional expression in others
(Erickson & Newman, 2007) compared to nonanxious controls. Therefore, interper-
sonal problems, such as clients’ maladaptive ways of relating to others, and deficits in
emotional experience have been targeted through incorporation of interpersonal and
experiential techniques in the context of cognitive behavioral treatment.
Based on Safran and Segal’s (1990) integration of CBT and interpersonal tech-
niques, Newman and colleagues at the Pennsylvania State University adapted this
approach for individuals with GAD and added an experiential focus with the objective
of identifying problematic relationship patterns and facilitating emotional deepening
(Newman, Castonguay, Borkovec, & Molnar, 2004). Dysfunctional relationship pat-
terns were addressed through the exploration of past and current relationships and
identification of ways in which clients create and maintain interpersonal problems,
and adoption of alternative ways of relating to others, and use of the therapeutic
relationship to explore cognitive and affective processes and challenge interpersonal
schemas (Newman et al., 2004). Emotional awareness and deepening involved track-
ing markers of emotionality (e.g., changes in voice quality or pace of conversation) that
signified emotional disruption or disengagement and use of experiential techniques to
engage clients’ comfort and exposure to their emotional experience (Newman et al.,
2004). This treatment was initially tested in an open trial with very promising results
(Newman, Castonguay, Borkovec, Fisher, & Nordberg, 2008).
In the first comparison between standard CBT and an attempt to improve CBT in
a randomized controlled trial of CBT for GAD (Newman et al., 2011), participants
were assigned to either CBT plus supportive listening (SL; n = 40) or CBT plus
interpersonal/emotional processing therapy (I/EP; n = 43) using an additive design.
Both treatments resulted in significant improvement in symptoms at posttreatment.
Therapeutic gains were maintained at 2-year follow-up, such that 75% of participants
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1014 Specific Disorders

in the CBT plus I/EP condition and 63.6% of participants in the CBT plus SL
condition no longer met diagnostic criteria for GAD at follow-up, an improvement
over an average of 50% of participants achieving high end-state functioning found in
previous studies. However, CBT plus I/EP was not statistically superior to CBT plus
SL on any outcome measure. In an effort to understand these null findings, Newman
et al. (2011) provide the following hypotheses: (a) the I/EP techniques chosen may
not have been sufficient to address participants’ interpersonal or emotional difficulties;
(b) I/EP techniques may have been efficacious, but were not superior to SL; and (c)
CBT plus I/EP may only be superior for some types of clients with GAD, such as those
with interpersonal or emotional difficulties. Although between-group differences were
not found, interpersonal problems at posttreatment demonstrate negative associations
with posttreatment and follow-up symptom improvement (Borkovec et al., 2002);
therefore this area would benefit from further investigation.

Emotional contrast exposure therapy. One additional theory about the failure of
the I/EP therapy was put forth by Newman and Llera (2011). These authors
theorized that it is possible that I/EP failed to target the aspect of emotions most
feared and avoided by participants with GAD. Newman and Llera (2011) point to
literature that suggests that rather than enable emotional avoidance, worry elicits and
sustains negative emotionality as a means to avoid an emotional contrast experience
(Brosschot, Gerin, & Thayer, 2006). Data show that worriers prefer to focus on an
unlikely catastrophic outcome as opposed to being taken off guard or surprised by
such an outcome. Therefore, Newman and Llera proposed that what worriers fear
and avoid is not emotion per se but rather an emotional contrast experience (e.g.,
a sharp shift in emotions from feeling fine to suddenly feeling badly). The solution
proposed by these authors is a treatment that exposes participants to the emotional
contrast experience (e.g., relaxation immediately before emotional exposure).

Emotion regulation therapy. The emotion dysregulation model of GAD underscores

the importance of emotion during the worry process (Mennin, Heimberg, Turk,
& Fresco, 2002). Specifically, emotion dysregulation is captured in (a) heightened
intensity of emotions, (b) poor understanding of emotions, (c) negative reactivity to
one’s emotional state, and (d) maladaptive emotional management responses (Mennin
et al., 2002). Preliminary evidence in support of this model found that individuals with
GAD rated their emotional experiences as significantly more intense, and experienced
more difficulty describing the motivational content of emotions, understanding their
reactions to shifts in emotional state following mood induction, and self-regulating
following a negative mood, and reported greater fear of negative and positive emotions
than control participants (Mennin et al., 2005). Likewise, deficits in emotional clarity,
acceptance of emotions, ability to engage in goal-directed behaviors when distressed,
impulse control, and access to emotion regulation strategies have been associated with
worry and analog GAD (Salters-Pedneault, Roemer, Tull, Rucker, & Mennin, 2006).
Thus, emotion regulation therapy (ERT) was established to address the emotional
avoidance of individuals with GAD. ERT integrates experiential and psychody-
namic treatment components into a cognitive behavioral framework, and focuses on
cognitive, emotional, and contextual factors contributing to the maintenance of GAD
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Generalized Anxiety Disorder 1015

(Mennin, 2006). ERT aims to help individuals with GAD (a) to understand and
increase acceptance of their emotional experiences, (b) to enhance their ability to
cope effectively with their emotions, (c) to decrease use of worry and other emotional
avoidance strategies, and (d) to incorporate affective information when identifying
needs, making decisions, motivating behavior, and relating to others (Mennin, 2006).
To achieve these therapeutic objectives, treatment currently comprises four phases.
Phase I focuses on psychoeducation about GAD and use of self-monitoring to track
worry and identify functional patterns of worry and emotions. Phase II centers on
enhancing awareness of bodily reactions and developing emotion regulation skills.
Phase III involves application of skills during exposure to emotionally salient con-
tent. Finally, Phase IV focuses on relapse prevention, termination of the therapeutic
relationship, and future goals (Mennin, 2006). Mennin and colleagues are in the
process of conducting a randomized controlled trial to examine the utility of ERT in
individuals with GAD. Results of this study will have implications for the functionality
of this etiological model and innovative treatments for GAD.

Integration of mindfulness-/acceptance-based techniques. Conceptualizing worry as a

form of avoidance (Borkovec et al., 2004) is central to the application of acceptance-
based treatments to GAD (Roemer & Orsillo, 2002). One particular model of
experiential avoidance suggests that psychological and emotional difficulties manifest
in response to attempts to control or mitigate negative internal experience (Hayes,
Wilson, Gifford, Follette, & Strosahl, 1996). Hayes, Strosahl, and Wilson (1999)
indicate that maladaptive behavior patterns sustained by experiential avoidance can
be modified by adopting a position of acceptance where a person acknowledges the
present moment and endeavors to reduce reliance on emotional and cognitive control
and increase pursuit of meaningful life goals (e.g., interpersonal relationships, physical
well-being) (Roemer & Orsillo, 2002). Acceptance and commitment therapy (ACT)
is an integrative treatment based on these principles and aims (a) to reduce use
of strategies employed to avoid internal experience (e.g., thoughts, feelings, bodily
sensations), (b) to decrease individuals’ negative and literal interpretations of their
thoughts, and (c) to increase individuals’ ability to commit to behavior change in
accordance with their values (Hayes et al., 1999; Roemer & Orsillo, 2002).
Mindfulness techniques, designed to increase awareness and present-moment focus,
have been incorporated into cognitive behavioral treatment for GAD. The objective of
focusing on the here-and-now and making use of all information in one’s environment
is to trade habitual, maladaptive behavioral patterns for more conscious, adaptive,
and flexible ways of responding (Roemer & Orsillo, 2002). The goal is for GAD
clients to eliminate unsuccessful attempts to control internal experience and promote
goal-directed activity (Hayes et al., 1999). Roemer, Orsillo, and Salters-Pedneault
(2008) examined the efficacy of acceptance-based behavioral therapy for GAD.
In comparison to a delayed treatment group, acceptance-based behavioral therapy
resulted in significant reductions in clinician-rated and self-reported GAD symptoms at
posttreatment and 3- and 9-month follow-up. At posttreatment, 77% of participants
achieved high end-state functioning. Overall, the integration of mindfulness- and
acceptance-based interventions into a cognitive behavioral framework demonstrates
promise for the treatment of GAD.
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1016 Specific Disorders

Conclusions

GAD is an intractable condition characterized by pathological worry and cognitive,

behavioral, and experiential avoidance that contribute to the maintenance of this dis-
order and engender significant impairment in life functioning. The last several decades
have been host to an increase in research dedicated to enhancing understanding of
the phenomenology and treatment of GAD. Cognitive behavioral interventions have
consistently demonstrated efficacy in reducing the core and associated symptoms of
GAD, including worry and positive and negative cognitions about worry, information
processing biases, intolerance of uncertainty, and use of avoidance strategies. New
variations on the cognitive behavioral approach to treating GAD have endeavored to
improve individuals’ end-state functioning by targeting areas of deficit (e.g., inter-
personal dysfunction, emotion dysregulation) not generally addressed in traditional
cognitive behavioral protocols. Whereas these integrative treatments have successfully
abated GAD symptomatology and resulted in long-term therapeutic gains, additional
studies utilizing dismantling/additive research designs are needed to evaluate treat-
ment components separately and in combination with the goal of establishing the
relative utility and incremental validity of those therapeutic components.

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Please note that the abstract and keywords will not be included in the printed
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Abstract: The uncontrollability and pervasiveness of worry central to generalized anxiety

disorder, its degree of comorbidity and chronic and fluctuating course, and its associated
psychosocial impairment underscore the need for highly effective treatments for generalized
anxiety disorder. Accordingly, cognitive behavioral therapy packages have been designed to
target cognitive, affective, behavioral, and somatic responses to perceived future threat that
are characteristic of individuals diagnosed with generalized anxiety disorder, and have typi-
cally included interventions such as self-monitoring, relaxation techniques, stimulus control,
self-control desensitization, and cognitive therapy. The efficacy of these methods has been
documented in a series of randomized controlled trials; however, recent research has centered
on enhancing treatment of generalized anxiety disorder given its severity and chronicity. Thera-
peutic advancement for generalized anxiety disorder has been made in the areas of interpersonal
and emotional processing therapy, emotional contrast exposure therapy, metacognitive therapy,
treatment of intolerance of uncertainty, integration of acceptance and mindfulness techniques
with cognitive behavioral therapy, and emotion regulation therapy.

Keywords: generalized anxiety disorder, GAD, worry, cognitive behavioral therapy,

randomized controlled trial