Cognitive-Behavioral Therapy

for Generalized Anxiety Disorder:

6
Case Formulation
and Evidence-Based Treatment
Strategies

Nicole J. LeBlanc, Anna Bartuska,

Lillian Blanchard, and Luana Marques

Generalized anxiety disorder (GAD) is a men- experience significant distress or functional

tal disorder characterized by its hallmark fea- impairment as a result of their worry in order to
ture: worry. Individuals with GAD experience meet the diagnostic criteria [1].
worry that is excessive, uncontrollable, and
occurs across multiple domains of life [1]. This
worry is accompanied by three or more of the Epidemiology
following symptoms: restlessness, fatigue, con-
centration difficulties, irritability, muscle ten- Epidemiological data from the World Health
sion, and sleep disturbance [1]. Worry and Organization (WHO) Mental Health Survey
associated symptoms must be present for more Initiative indicate that the global lifetime preva-
days than not, over a period of six months or lence of GAD is 3.7%, and the global 12-month
more, for a person to receive a formal diagnosis prevalence is 1.8% [2]. Both the lifetime and
of GAD according to the Diagnostic and 12-month prevalence rates vary across countries,
Statistical Manual of Mental Disorders, Fifth with the highest prevalence rates seen in high-
Edition (DSM-5; 1). A person must also income countries. In the United States, the life-
time prevalence is 7.8% and the 12-month
prevalence is 4.0% [2]. The prevalence of GAD is
higher among individuals who are female,
unmarried, not employed, and less educated [2].
N. J. LeBlanc (*) · L. Marques
Department of Psychiatry, Massachusetts General
Hospital, Boston, MA, USA
e-mail: [email protected];
Course
[email protected]
Data from the WHO Mental Health Survey
A. Bartuska
Department of Psychology, Palo Alto University, Initiative indicate that GAD typically develops in
Palo Alto, CA, USA early- to middle-adulthood, with 25% of cases
e-mail: [email protected] developing by age 25, 50% of cases developing
L. Blanchard by age 39, and 75% of cases developing by age
Department of Psychological Sciences, University of 53 [2]. After onset, GAD is typically a chronic
Connecticut, Storrs, CT, USA
e-mail: [email protected]
disorder if not treated [2].

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 65

S. E. Sprich et al. (eds.), The Massachusetts General Hospital Handbook of Cognitive Behavioral
Therapy, Current Clinical Psychiatry, https://doi.org/10.1007/978-3-031-29368-9_6
66 N. J. LeBlanc et al.

Impact Notably, many of these regions are found in the

default mode network, a resting state network
A significant proportion of people with GAD that has been shown to be active during self-
report severe impairment at home (28.0%), at referential thinking and may contribute to
work (32.1%), in close relationships (31.1%), excessive worry [8]. Functional data further
and in social relationships (34.9%), with approxi- suggest aberrant activity within key regions of
mately half reporting severe impairment in at the executive control network (dlPFC) and
least one life domain [2]. Individuals with GAD salience network (amygdala) [7]. Atypical con-
in the past year report an average of 41.2 days out nectivity within these three networks is thought
of their role per year [2]. For those who are work- to underlie a wide range of psychopathologies,
ing, 34% of individuals with GAD report a work including anxiety [9].
productivity reduction of 10% or more [3].
Impairment is typically greater among those with
co-occurring disorders [3]. One of the most fre- Psychological Factors
quent co-occurring disorders is major depressive
disorder (MDD), with research suggesting that As discussed, studies have shown a strong and
52.6% of individuals with lifetime GAD also reliable association between the personality trait
experience lifetime MDD [2]. neuroticism and GAD. Neuroticism (also called
trait negative affect or dispositional negativity)
describes the tendency for a person to experience
Etiology frequent negative emotions in daily life [10].
Studies show that neuroticism is strongly corre-
Numerous factors have been implicated in the lated with core symptoms of GAD, including
development and maintenance of GAD, includ- anxious mood and worry [10, 11].
ing biological, psychological, and social factors. Individuals with GAD also demonstrate spe-
cific cognitive biases that may contribute to the
development and maintenance of the disorder.
Biological Factors People with GAD are more likely to attend to
threatening information in the environment com-
Research suggests that there is a significant pared to individuals without a mental disorder
genetic component to GAD. Findings from a [12]. This attention bias is seen across different
meta-analysis of family and twin studies indicate domains of threats (e.g., social threats and physi-
that GAD has a heritability of 31.6% [4]. Much cal threats), which is consistent with the general-
of the genetic risk for GAD may overlap with ized nature of worry in GAD [12]. Individuals
genetic risk for the personality trait neuroticism with GAD are also more likely to interpret
(i.e., trait negative affect), as the genetic correla- ambiguous situations in a threatening manner
tion between GAD and neuroticism is estimated (e.g., interpreting a loud noise as indicative of an
to be 0.80 [5]. Like other mental disorders, intruder) [13].
genetic risk for GAD is likely heterogeneous and Finally, certain beliefs and cognitive schemas
caused by interactions between multiple genes have been implicated in the development and
with small effects [6]. maintenance of GAD. Negative beliefs about
Neuroimaging studies have also contributed worry, such as the belief that worry is physically
to our understanding of the neurobiology of or mentally dangerous, or the belief that it is
GAD. A recent systematic review and meta- impossible to control worry, are both associated
analysis indicate that patients with GAD have with GAD [14]. Intolerance of uncertainty, or the
altered physiology in the dorsolateral prefrontal belief that uncertain situations are threatening
cortex (dlPFC), anterior cingulate cortex and unbearable, is also associated with a diagno-
(ACC), amygdala, and hippocampus [7]. sis of GAD [15].
6 Cognitive-Behavioral Therapy for Generalized Anxiety Disorder: Case Formulation and… 67

Social Factors ports the hypothesis that the etiology of GAD is

heterogenous and that personalized treatment
Stressful life events have been consistently may optimize outcomes [21].
linked to the development of GAD. Stressful
experiences in childhood, such as growing up
with few economic resources or having a dys- Treatment
functional family environment, predict increased
risk for GAD in adulthood [16, 17]. Recent Cognitive-behavioral therapy (CBT) is the best-
stressors also predict the onset of GAD among studied psychotherapy for GAD and has a strong
adults [16, 18]. Specifically, stressful events evidence base [22]. A meta-analysis of random-
involving possible future loss (e.g., threats of ized controlled trials demonstrated that CBT is
future job loss and relationship conflict) or cur- superior to active control conditions (e.g., sup-
rent loss (e.g., death of a loved one, divorce) pre- portive counseling and pill placebo) for the treat-
dict the onset of GAD symptoms in the following ment of GAD with a large effect size (Hedge’s
month [18]. g = 1.01; [23]). On average, individuals with
GAD who complete a course of CBT score within
the normative range on a self-report measure of
Etiological Processes worry, and these gains are typically maintained
for at least one year after treatment [24].
The etiology of GAD likely involves complex An in-depth review of other treatments for
interactions between biological, psychological, GAD is beyond the scope of this chapter. Briefly,
and social risk factors, and researchers are several selective serotonin reuptake inhibitors
beginning to explore how these factors may and selective serotonin-norepinephrine reuptake
interact to increase the risk for the disorder. For inhibitors have received empirical support across
example, one model proposes that vulnerability multiple randomized controlled trials [25].
factors, such as childhood family dysfunction, Mindfulness-based treatments, such as
childhood trauma, and genetic risk, interact mindfulness-based stress reduction, have also
with current stressors to lead to the development received empirical support [26]. More research is
of GAD [19]. Another model, termed the needed to understand how to match patients to
Network Model of mental disorders, proposes treatments and whether and how to combine
that risk factors lead to the development of indi- treatments to optimize patient outcomes.
vidual symptoms, and these symptoms then
cause other symptoms [20]. For example, bio-
logical risk factors could underlie a propensity Cognitive-Behavioral Therapy
toward uncontrollable worry, which then causes for GAD
other symptoms of GAD, such as irritability or
difficulty sleeping. Assessment
Research on the etiology of GAD is further
complicated by the fact that there are almost cer- CBT for GAD begins with a thorough psychodi-
tainly a myriad of etiological pathways to the dis- agnostic assessment. A structured diagnostic
order. Researchers have used ecological interview, such as the Structured Clinical
momentary assessment methods to collect inten- Interview for DSM-5 (SCID-5; [27]) or the Mini
sive time-series data from people with GAD and International Neuropsychiatric Interview (MINI
have then examined how their symptoms change 7.0.2; [28]), can be used to assess for the pres-
and interact over time [21]. Results of this ence of GAD as well as comorbid disorders.
approach demonstrate considerable variability in Self-report measures can be used to support
the symptom profiles and symptom dynamics diagnostic decision-making, inform case concep-
among people with GAD [21]. This finding sup- tualization, and track symptoms over the course
68 N. J. LeBlanc et al.

of CBT. The Generalized Anxiety Disorder maintaining the patient’s GAD symptoms.
7-Item Scale (GAD-7) is a brief, self-report mea- Knowledge of theoretical cognitive-behavioral
sure that assesses GAD symptom severity over models of GAD can help with case conceptual-
the past two weeks [29]. A score of 10 on the ization, and these models include the Avoidance
GAD-7 is the optimal cut point for identifying Model of Worry [36] the Intolerance of
potential cases of GAD with high sensitivity and Uncertainty Model [37], the Metacognitive
specificity [29]. The Penn State Worry Model of Worry [38], the Emotion Dysregulation
Questionnaire (PSWQ) is another self-report Model of GAD [39], and the Acceptance-based
measure that assesses a person’s propensity to Model of GAD [40]. Each of these models has
engage in worry [30]. Both the GAD-7 and the received empirical support and serves as the basis
PSWQ are sensitive to change over the course of of an empirically supported CBT protocol for
CBT [31]. In addition, the Penn State Worry GAD (for a review see [41]).
Questionnaire-Past Week (PSWQ-PW) is an CBT models of GAD focus on explaining the
adaptation of the PSWQ that captures weekly factors that cause and/or reinforce worry. Worry
fluctuation in worry and is particularly useful for is typically conceptualized as an ineffective strat-
assessing symptom change during CBT [32]. egy that a person uses to cope with negative emo-
Research suggests there are CBT for GAD tions. Individual differences that predispose a
begins with a thorough psychodiagnostic assess- person to experience strong emotions (e.g., high
ment. Cultural differences in the expression and emotional reactivity and high intolerance of
experience of anxiety (e.g., [2, 33]). It is there- uncertainty) may increase the chances that they
fore helpful to explore how the patient’s racial, will engage in habitual worry. Once initiated,
ethnic, and/or cultural identity may impact their worry is maintained over time through a process
symptom presentation and expectations for treat- of negative reinforcement. Specifically, a person
ment. Questions such as “how do you identify may feel that worry is helpful in the short term
your racial or ethnic background?” and “how has because it suppresses physiological sensations of
your race, ethnicity, and/ or cultural background anxiety and distracts their attention away from
impacted your experience of anxiety?” are help- frightening mental images of worst-case scenar-
ful for learning more about a patient and pre- ios. However, in the long term, worry prevents
venting the therapist from making inaccurate them from habituating to threatening mental
assumptions [34]. Furthermore, the therapist images and from cultivating more effective emo-
should consider how cultural variables, such as tion regulation strategies. Worry eventually
the patient’s preferred language, familiarity with becomes a habitual and inflexible response to
psychological testing, educational background, fear and anxiety, and a person develops
and level of acculturation, may impact the GAD. CBT models suggest that treatment for
assessment process, and use this awareness of GAD should therefore involve psychoeducation
CBT for GAD begins with a thorough psychodi- about emotions, self-monitoring of cognitive and
agnostic assessment to inform measure selec- behavioral reactions to anxiety triggers, and
tion, administration, and interpretation of results guided practice with more effective emotion reg-
[35]. ulation strategies such as applied relaxation,
mindfulness, and cognitive reappraisal. Several
CBT protocols also recommend the use of imagi-
Cognitive-Behavioral Case nal exposure to help patients learn to tolerate the
Conceptualization discomfort associated with threatening mental
images.
Following the initial assessment, the CBT for In addition, several CBT models emphasize
GAD begins with a thorough psychodiagnostic the importance of specific beliefs in the develop-
assessment. Therapist can begin to develop a ment and maintenance of GAD. For example,
cognitive-behavioral formulation of the factors negative beliefs about one’s ability to cope with
6 Cognitive-Behavioral Therapy for Generalized Anxiety Disorder: Case Formulation and… 69

uncertainty or handle future problems lead to an Cognitive-Behavioral Treatment

over-reliance on worry and should be targeted for Strategies for GAD
change. Positive and negative beliefs about worry
(e.g., “Worry prevents negative outcomes” or Goal Setting
“Worry can lead to a mental breakdown”) also
perpetuate the worry process. When present, CBT often begins with goal setting in order to
these beliefs can be addressed in CBT for GAD increase the patient’s motivation for treatment
using cognitive reappraisal and/or behavioral [42]. The therapist begins by providing psychoed-
experiments. Finally, the models emphasize ucation about the importance of setting goals to
avoidance behaviors (e.g., thought suppression, support behavior change. The therapist then invites
behavioral restriction, over-preparation, perfec- the patient to set their own goals for treatment,
tionism) as a maintenance factor for GAD, given either through discussion in the session or by fill-
that these behaviors reduce distress in the short ing out a worksheet for homework. The therapist
term but interfere with emotion regulation and can ask follow-up questions (e.g., “What would it
life functioning in the long term. The CBT strat- look like if you achieved your goal?”) to help the
egy of valued actions involves teaching patients patient make their goals more specific. The thera-
to approach meaningful life activities while elim- pist should check-in with the patient throughout
inating avoidance behaviors. treatment regarding their progress toward their
In sum, CBT for GAD involves teaching goals. The therapist can also link treatment exer-
patients to recognize their ineffective responses cises (e.g., valued actions) directly to these goals.
to anxiety triggers and to employ more effective
emotion regulation strategies when feeling fear
or anxiety. Common treatment strategies include Psychoeducation
psychoeducation, self-monitoring of worry epi-
sodes, applied relaxation, mindfulness exercises, Psychoeducation is used at the beginning of CBT
cognitive reappraisal, behavioral experiments, for GAD to increase the patient’s knowledge of
imaginal exposure, and valued actions. In the their anxiety and confidence in the treatment pro-
following section, we describe each of these cess [42–47]. Psychoeducation begins with a dis-
strategies in more detail. Given the heteroge- cussion about the adaptive function of emotions.
neous nature of GAD, different strategies may The patient is encouraged to consider how emo-
be more or less applicable for different patients. tions can be beneficial in their lives. For example,
The therapist can use their cognitive-behavioral the therapist can use Socratic questioning to ask a
formulation to select specific treatment strate- patient about the sensations they might feel in
gies for individual patients. For example, a ther- their body if they were face-to-face with a lion.
apist might note that a patient possesses strong The therapist guides the patient in discovering
negative beliefs about worry and therefore the helpfulness of uncomfortable physiological
emphasizes strategies to target these negative states (e.g., increased heart rate and muscle ten-
beliefs. However, the field currently lacks evi- sion) that accompany our natural tendency to feel
dence-based tools for matching patients to spe- fear in response to threat. The fact that the func-
cific treatment strategies, which leaves therapists tion of anxiety is to help us anticipate and prepare
with limited explicit guidance on how to select for future threats is also discussed. Once the
and sequence cognitive-behavioral strategies. patient understands the utility of emotions like
Another option is to use an empirical approach fear and anxiety, the therapist explains the pro-
and teach each of the strategies described below cess by which these emotions can become prob-
to a patient, while observing the specific strate- lematic. The patient learns that maladaptive
gies that resonate and improve their symptoms. responses to fear and anxiety, such as worry and
This latter approach is illustrated in the case avoidance, can cause these emotions to become
vignette that follows. too intense, diffuse, and long-lasting.
70 N. J. LeBlanc et al.

The second phase of psychoeducation is to can also draw the patient’s attention to behaviors
introduce the patient to the cognitive-behavioral that may be maintaining anxiety in the long term,
model of emotions, which is called the three- such as perfectionism, procrastination, or efforts
component model. The therapist explains that the to suppress thoughts. Self-monitoring should
three-component model allows the patient to continue throughout CBT for GAD, and patients
understand the elements of an emotional response can begin to monitor which CBT strategies they
(i.e., thoughts, physical sensations, and behav- use to cope with worry episodes when they arise.
iors) in real-time and to notice how these ele-
ments interact with one another. The therapist
begins by asking for a recent example of anxiety Applied Relaxation
from the patient’s life. While the patient describes
the situation and their experiences, the therapist Applied relaxation can be used in CBT for GAD
writes down their thoughts, physical sensations, [43] and is also effective as a standalone treat-
and behaviors and uses arrows to show how these ment for GAD [49]. The goal of applied relax-
elements build on one another over time in a ation is to teach patients a proactive coping
cycle. The therapist then links the three- strategy to use in response to anxiety triggers.
component model to the prior discussion about Patients cultivate applied relaxation skills through
emotions by demonstrating how specific thoughts graduated practice (see 49 for more detail). The
(e.g., negative predictions) and behaviors (e.g., first step is to teach the patient progressive mus-
avoidance) likely intensified the patient’s anxiety cle relaxation (PMR) in session. The patient is
beyond a level that was helpful in that moment. instructed to sit in a chair, close their eyes, and
Finally, the therapist provides psychoeducation relax. The therapist then asks the patient to tense
about the CBT strategies that will interrupt this their lower arms and hands, to hold the tension
process. for 10 seconds, and to relax the tension. The pro-
cess continues sequentially for different muscle
groups including upper arms, forehead, eyes/
Self-Monitoring nose, mouth/jaw, neck, chest/shoulders, abdo-
men, upper legs, and lower legs/feet. The practice
Self-monitoring of worry episodes is used ends with the patient relaxing all parts of their
throughout CBT for GAD to help patients body while thinking the word “relaxing.” The
become more aware of the connection between patient is given an audio recording of the full
their thoughts, physical sensations, and behaviors PMR procedure and is encouraged to practice the
during worry episodes [43–45]. The majority of exercise twice per day. Once the patient becomes
self-monitoring takes place outside of the therapy proficient with the 16-muscle group procedure,
sessions. The patient is asked to identify worry they learn and practice abbreviated PMR proce-
episodes throughout the week and to record the dures including the -eight-muscle group and
trigger for each worry episode; their thoughts, four-muscle group procedures. They can also
physical sensations, and behaviors during each practice relaxing nonessential muscle groups
worry episode; and the outcome of each worry during daily activities, such as relaxing the shoul-
episode (i.e., what happened next). Historically, ders while walking. The final step is to teach the
paper logs were given to patients to assist with patient rapid relaxation. The patient is instructed
self-monitoring. However, mobile applications to take a deep breath, think the word “relaxing”,
have been developed with emotion-tracking scan their body for tension, and release any tight-
capabilities that may be helpful for self- ness. The therapist encourages the patient to
monitoring (e.g., [48]). In the next session, the practice rapid relaxation multiple times a day in
therapist and patient review the log of worry epi- both calm and stressful situations (e.g., at work).
sodes together. The therapist may point out cir- Eventually, the patient can use rapid relaxation to
cumstances that frequently bring on anxiety and interrupt a worrying episode.
6 Cognitive-Behavioral Therapy for Generalized Anxiety Disorder: Case Formulation and… 71

Mindfulness Exercises ambiguous situation to the patient (e.g., “Imagine

you call your coworker to discuss a presentation
Mindfulness is another strategy that can be inte- you are working on. The phone rings a few times
grated into CBT for GAD [45, 46] or used as a but your coworker declines the call.”). The thera-
standalone treatment for GAD [26]. The goal of pist then asks the patient how they might interpret
mindfulness in CBT for GAD is to help patients this situation (e.g., my coworker is upset with me)
observe and accept their internal experiences and how that interpretation would make them feel
(i.e., their thoughts, emotions, and physical sen- (e.g., sad). The therapist then prompts the patient
sations) without reacting to them in automatic, to generate alternative interpretations (e.g., my
ineffective ways. Many different mindfulness coworker was in another meeting) and to describe
exercises can be used to achieve these goals, how these alternative interpretations would make
including guided meditations, yoga practices, them feel (e.g., calm). The therapist summarizes
and body scans. A common introductory exercise by explaining that people with GAD often make
is mindfulness of breath (see [50] for more automatic interpretations that are overly negative,
detail). The therapist asks the patient to close and these negative interpretations can lead to
their eyes and direct their attention inward to emotions that are inconsistent with the facts of the
their breathing. The patient is encouraged to situation. For example, people with GAD often
attend to the sensation of their breath moving generate overly negative predictions about future
through their nose, mouth, and chest. If addi- events and view problems as threatening, both of
tional thoughts or emotions arise, the patient is which lead to frequent fear and anxiety [43, 44].
instructed to observe the unexpected sensations Cognitive reappraisal involves learning to notice
without judgment and gently return their atten- these negative interpretations in daily life and
tion to their breath. Other mindfulness exercises practicing generating more accurate and helpful
include guided meditations for mindfulness of interpretations.
thoughts, emotions, or physical sensations [50]. The therapist can use a worksheet to introduce
Formal mindfulness exercises are typically com- questions that will assist the patient in examining
pleted in the treatment session and assigned as their automatic interpretations. If a patient is
practice between sessions. In addition, the patient assuming that the worst possible outcome will
can incorporate informal mindfulness practice happen, questions like, “What is the evidence for
into daily life, such as mindfully observing bodily and against your prediction?” and “How else
sensations while completing daily tasks, like eat- might the situation turn out?” can help them con-
ing or walking. sider alternative outcomes. If a patient is underes-
timating their ability to cope with a problem,
questions like, “What’s the worst that could hap-
Cognitive Reappraisal pen and how would you handle that?” can assist
the patient in identifying coping strategies. After
Cognitive reappraisal (also called cognitive the patient has considered these questions, they
restructuring or challenging negative automatic should generate an alternative interpretation that
thoughts) is a core CBT strategy used across treat- summarizes their new perspective. The therapist
ment protocols [42–45]. Broadly, the goals of should encourage the patient to practice cognitive
cognitive reappraisal are to help patients notice reappraisal frequently so that the skill becomes
their automatic interpretations of situations, automatic over time.
understand the connection between their auto-
matic interpretations and their emotions, and
learn to generate more accurate and helpful inter- Behavioral Experiments
pretations in daily life. To teach cognitive reap-
praisal, the therapist first provides psychoeducation Behavioral experiments are used in CBT for
about automatic interpretations through the use of GAD to help patients modify beliefs that are
an example situation. The therapist poses an maintaining their symptoms [47, 51]. This
72 N. J. LeBlanc et al.

strategy is particularly useful in modifying nega- makes an audio recording of the account, listens
tive beliefs about uncertainty as well as positive to the recording daily, and rates their peak level
or negative beliefs about worry [47, 51]. The of discomfort on a scale from 0 to 100, for each
therapist and patient first use the patient’s self- exposure. The patient is encouraged to continue
monitoring and cognitive-behavioral case practicing the exposure daily until their peak dis-
formulation to identify specific beliefs that may comfort comes down by half. Once the patient
be maintaining the patient’s symptoms. The ther- has habituated to the first feared image, they
apist and patient then devise various behavioral repeat the process for other core fears.
experiments to test the accuracy of these beliefs.
For example, to test the belief, “I can’t control
my worries” the patient could designate a daily Valued Actions
30-minute period during which they are allowed
to worry and try to postpone worrying until their Valued actions is a strategy that can help patients
“worry time” each day. Behavioral experiments reduce avoidance and improve their overall level
can be conducted both in session with the thera- of functioning [45, 46]. To practice valued
pist and for homework. For each behavioral actions, the therapist first asks the patient to iden-
experiment the patient should use a worksheet to tify ways in which anxiety and avoidance are pre-
record: (1) the belief being tested, (2) details of venting them from living according to their
the behavioral experiment (e.g., where, when, values in three domains: relationships, work/
what, and with whom), (3) the anticipated out- school, and hobbies/self-care. The therapist and
come of the experiment, and (4) the actual out- patient then brainstorm behaviors (i.e., valued
come of the experiment [51]. Behavioral actions) that the patient could do to act in line
experiments that are completed for homework with their values in these domains. Finally, the
should be discussed in the following session to patient commits to practicing one valued action
reinforce the patient’s learning. for homework. Importantly, the therapist empha-
sizes that the goal is for the patient to perform the
valued action even if it brings on uncomfortable
Imaginal Exposure thoughts, emotions, or physical sensations. In
addition, the patient should eliminate any avoid-
Cognitive-behavioral models of GAD suggest ance behaviors (e.g. reassurance seeking and per-
that people engage in worry as a way to avoid fectionism) designed to lessen their discomfort
upsetting mental images of core fears. Imaginal while practicing the valued action. Ultimately,
exposure is a CBT technique that counteracts this this strategy is designed to teach the patient that
process by having patients repeatedly confront they can handle discomfort while doing the
mental images of core fears until they no longer things they care about. Over time, the therapist
elicit strong levels of anxiety [44]. To practice should encourage the patient to practice multiple
imaginal exposure, the therapist first helps the valued actions across life domains.
patient identify worry themes from their self-
monitoring. The therapist then helps the patient
identify the core fear for each worry theme by Clinical Application: Case Vignette
asking them to describe the worst possible out-
come for that worry. For example, a patient who Initial Evaluation
worries about the health of their spouse might say
that their worst fear is receiving the news that Elena is a 35-year-old, Latina, married, female,
their spouse died unexpectedly. The patient then who presents for evaluation of persistent worry
writes a detailed account of the feared image in symptoms. Specifically, she reports persistent
vivid, sensory detail and reads the account aloud worry in multiple domains of her life including
in the first-person, present tense. The patient worries about work (e.g., making mistakes, meet-
6 Cognitive-Behavioral Therapy for Generalized Anxiety Disorder: Case Formulation and… 73

ing deadlines, and being fired), her family (e.g., speaking in full sentences. I started to think
her husband’s health, her daughter’s cognitive, about my daughter and I got nervous that she
and social development), and day-to-day matters is falling behind developmentally.
(e.g., being late to appointments and making Therapist: So, you saw this video and it made
small decisions). Although she has been a worrier you feel anxious. Let’s break this emotion
for her entire life, her symptoms began to cause down into three parts: thoughts, physical sen-
significant distress for her at the age of 23 when sations, and behaviors. We’ll start with
she enrolled in law school. She is pursuing treat- thoughts. What were you saying to yourself in
ment now because her worry symptoms are mak- that moment that was making your feel
ing it difficult for her to focus on her work and anxious?
are also leading to frequent arguments with her Elena: I was thinking, “Something is wrong with
husband. During the evaluation, Elena scores a my daughter, she’s falling behind.”
17 on the GAD-7 (severe GAD) and a 72 on the Therapist: And when you were having that
PSWQ-PW. thought, what physical sensations did you
have in your body?
Elena: I felt sick to my stomach, and my fore-
Session One head and shoulders tensed up.
Therapist: And what was your behavior, what
The therapist begins the first session by encour- did you do in that moment?
aging Elena to identify her goals for treatment. Elena: Well … I started to look online for differ-
At first, Elena responds vaguely that she hopes ent articles about language development and
to reduce her overall level of anxiety and worry. signs of developmental delays. I tried to dis-
The therapist acknowledges that anxiety reduc- tract myself with work, but my mind kept
tion is Elena’s general motivation for engaging coming back to the worry and so I would read
in CBT, however, the therapist urges her to iden- another article.
tify more specific treatment goals. Elena states Therapist: Now that we’ve separated these parts,
that she would like to learn strategies to interrupt we can start to think about how they interact.
worry loops at work, reduce the frequency of How did the thought, “Something is wrong
arguments with her husband, and sleep an aver- with my daughter,” influence your physical
age of seven hours each night. The therapist then sensations?
teaches Elena the three-component model of Elena: It made me really nervous, and when I’m
emotions. nervous I usually feel sick and tense.
Therapist: And how did your thoughts and sen-
Therapist: Can you tell me about a recent time sations influence your behavior?
that you felt anxious? Elena: I hate feeling anxious, so I was trying to
Elena: Yesterday at work … I was so anxious I find something online to reassure me that she
didn’t get anything done all morning. is going to be okay.
Therapist: Okay, let’s think back to yesterday. Therapist: Did it work?
First, we want to identify the situation that Elena: Not really, I found a lot of conflicting
triggered your anxiety. Emotions rarely come information online. Every time I tried to work,
out of nowhere, and usually there is something my mind would circle back to something I
that prompts an emotion to occur. Can you read in the article and I would start to feel ner-
remember what was happening just before vous and worry again.
you started to feel anxious? Therapist: This example shows the strong con-
Elena: I saw a video a friend had posted online. nection between our thoughts, physical sensa-
It was of her daughter who is 2-years-old tions, and behaviors. Your worry thoughts,
74 N. J. LeBlanc et al.

physical symptoms, and behaviors, built on the 16-muscle group PMR procedure and creates
one another to keep the anxiety going. What an audio recording. For homework, Elena agrees
was the consequence? What happened next? to practice PMR daily and to continue self-
Elena: I didn’t get any work done and I was so monitoring of worry.
mad at myself.
Therapist: Thanks for sharing this example with
me. Once you get some practice breaking Sessions Three and Four
emotions down into these three parts, I’ll teach
you skills to interrupt the cycle that keeps neg- In addition to continued practice with PMR, the
ative emotions going. primary focus of sessions three and four is on
cognitive reappraisal. The therapist and Elena use
For homework, Elena agrees to complete self- her self-monitoring forms to identify examples of
monitoring of worry episodes using the structure negative interpretations during worry episodes.
of the three-component model. The therapist then teaches Elena the steps to
reappraise these negative interpretations.

Session Two Therapist: From your homework this week, we

saw that you got stuck in a worry loop when
The therapist begins session two by reviewing you had to decide which preschool to choose
Elena’s homework. Together, the therapist and for your daughter. You felt anxious and had
Elena begin to notice common triggers for the thought, ‘I have to make the right choice,
Elena’s anxiety, including indicators that some- or else she’ll be unhappy.”
thing could be wrong with her husband or daugh- Elena: I just kept thinking about what it would be
ter, situations in which has to make decisions, like to drop her off every day and was worry-
and making mistakes at work. These triggers ing that she’d be miserable and wouldn’t want
typically lead to catastrophic interpretations to go inside.
(e.g., “We’re going to lose our most important Therapist: Let’s take a closer look at your pre-
client”) as well as physiological symptoms of diction using our worksheet. Do you have any
anxiety including nausea, rapid heartbeat, and evidence to support the prediction that she’ll
sweating. In response to these thoughts and sen- be unhappy at preschool?
sations, Elena typically engages in avoidance Elena: Well, she’s shy. It takes her a long time to
behaviors intended to lessen her distress, includ- warm up to other people.
ing mentally reviewing the details of the situa- Therapist: Okay, so it might take her some time
tion, seeking reassurance from others, to adapt to preschool. Do you have any evi-
researching online, or creating elaborate to-do dence against the prediction that she’ll be
lists. The therapist uses Socratic questions to unhappy?
help Elena explore how these behaviors tempo- Elena: I don’t think so.
rarily reduce her anxiety in the short-term but Therapist: In the past, when she met someone
actually perpetuate her anxiety and worry in the new, how many days did it take before she
long term. seemed comfortable with that person?
The therapist then introduces Elena to Elena: With our nanny, it took about a week
Progressive Muscle Relaxation (PMR). The ther- before she seemed comfortable. But she usu-
apist explains that Elena will learn a procedure to ally warms up to other kids quickly, in about a
systematically tense and relax her muscles and day.
that eventually she will be able to employ this Therapist: So, it sounds like it will probably take
technique during moments of heightened anxiety. her between one day to one week to get used
Elena is initially skeptical of PMR but she agrees to preschool?
to try the skill. The therapist guides her through Elena: Yes, I guess that’s true.
6 Cognitive-Behavioral Therapy for Generalized Anxiety Disorder: Case Formulation and… 75

Therapist: What are the real odds that she’ll be acknowledges this challenge and explains to
permanently unhappy at preschool? Elena that the brain naturally generates many
Elena: She’s adapted to new people and places in thoughts each day and it is not always necessary
the past, but preschool is a big change. I’d say to respond to each one. An alternative strategy
there’s a 5% chance she won’t get used to it. when we notice our mind wandering to worry
Therapist: Okay, and let’s say that a few weeks thoughts is to gently refocus on the present
go by, and she still seems unhappy at drop moment. Elena agrees to listen to an audio
off – what would you do then? recording of this mindfulness exercise daily and
Elena: I would talk with her teachers about ideas to practice noticing worry thoughts in daily life
to make her feel more comfortable. without responding to them.
Therapist: That’s a good idea. And what would
you do if that didn’t work?
Elena: At that point, I might consider finding a Session Six
different preschool.
Therapist: So, there are many different things At the beginning of session six, the therapist and
you could do to cope with the situation. Elena discuss her continued practice of PMR,
Elena: It would take a lot of time and effort to cognitive reappraisal, and mindfulness. The ther-
switch her to a different school, but it wouldn’t apist praises Elena for working hard to learn and
be the end of the world. practice these skills. Elena nods, but then tears up
Therapist: It’s normal to feel some anxiety when and says she still thinks worrying makes her
anticipating this big change for yourself and weak and is ashamed for needing CBT. The ther-
for your daughter. When you feel that anxiety apist asks Elena what she does when she has the
and have the thought, “she’s going to be thought, “worrying means I’m weak.” Elena
unhappy,” what do you want to remind replies that she tries to get rid of her worries by
yourself? focusing on something else, but the worries keep
Elena: I can remind myself that she’ll probably popping back into her mind. The therapist uses a
adapt to it and love it after a week or so. And whiteboard to show Elena how the thought, “wor-
there are a lot of things I can do to support her rying means I’m weak,” and the behavior of
through the process. pushing the worries away feed off of one another
to increase her anxiety. The therapist then encour-
After session three, Elena agrees to practice ages Elena to examine the belief, “worrying
cognitive reappraisal daily using a worksheet as a means I’m weak,” using a behavioral experiment.
guide. In session four, the therapist and Elena Elena identifies five people who she considers to
review her homework and work together to reap- be strong: her mother, her father, her aunt, her
praise any automatic interpretations that Elena best friend, and her sister-in-law. She agrees to
had difficulty challenging on her own. ask each of them how often they worry and to
bring the results of this experiment to the next
CBT session.
Session Five

In session five, the therapist leads Elena through Session Seven

a mindfulness exercise in which Elena closes her
eyes and practices observing her thoughts as The therapist begins session seven by asking
though they are clouds floating through the sky. about the results of Elena’s behavioral experi-
After the exercise, Elena and the therapist discuss ment. Elena reports that each person on her list
the experience. Elena reports that it was very dif- said that they worry about something at least
ficult to let thoughts pass through her mind with- once per week. The therapist and Elena reflect on
out spiraling into a worry loop. The therapist Elena’s original thought, “worrying means I’m
76 N. J. LeBlanc et al.

weak.” Elena acknowledges that worrying is Therapist: It’s very rare that the exact things
more common than she thought, and it seems like we’re worried about actually happen.
everyone does it once in a while. Worrying just isn’t that useful because we
The therapist asks Elena if she has any posi- can’t predict the future.
tive beliefs about worry. Elena admits that she Elena: I never thought about it that way, but it’s
thinks worrying helps her prepare for the future. true.
The therapist suggests Elena conduct another
experiment to test this belief.
Sessions Eight through Ten
Therapist: Let’s think about a recent time you
were worried about the outcome of an Sessions eight to ten focus on imaginal exposure.
event. The therapist assists Elena in identifying core
Elena: This week I was really worried because I fears connected to her most frequent worry
realized my car hadn’t had an oil change in themes. Her core fears are (1) that her daughter
over a year. I was so nervous that I had ruined will never become self-sufficient and will end up
the engine by waiting so long. homeless, (2) that she will lose her job and won’t
Therapist: I want you to take out a piece of paper be able to provide for her family, and (3) that her
and write down everything you were worried husband will die and she won’t be able to func-
about in that moment. tion. She begins working with the first core fear
Elena: I was worried I would take the car in for and creates an audio recording for the first feared
the oil change and the technician would tell image. Elena practices listening to the audio
me that I had caused thousands of dollars of recording daily for homework between sessions
damage. I was also worried that my husband eight and nine. In session nine, she and the thera-
would criticize me for waiting to get the oil pist observed that the feared image became less
changed. distressing over the course of the week. Elena
Therapist: Okay, now I want you to write down then creates an audio recording for her second
everything that ended up happening when you core fear and practices the exposure for home-
went to get your oil changed. work. She approaches the final imaginal expo-
Elena: The appointment took a while, but they sure during session ten and practices this for
had a little room where I could wait. After an homework.
hour or so, the technician came to tell me that
they changed the oil and the engine was fine.
He told me I needed new tires though, which Sessions Nine through Eleven
were expensive.
Therapist: Interesting … and what happened In sessions nine to eleven, Elena also begins to
when you got home and told your husband work on valued action. She and the therapist dis-
about the appointment? cuss ways that avoidance behaviors are prevent-
Elena: He realized he also hadn’t taken his car in ing her from living life according to her values in
for an oil change in a while. We tried to come the domains of relationships, work, and hobbies/
up with some sort of system to remind our- self-care. Elena observes that her tendency to
selves to do it in the future. repeatedly ask her husband questions about his
Therapist: Let’s compare the two sides of this physical health is annoying to him and leads to
paper. What do you notice about your original frequent arguments. To live more in line with her
worries versus what actually happened? values in the domain of relationships, Elena
Elena: Nothing that I was worried about hap- decides to plan a weekly outing with her husband
pened. I did have to pay for new tires, which and resist the urge to ask him about his health
was stressful. But in most ways, the situation during the outing. In the domain of work, Elena
turned out better than expected. realizes that her discomfort delegating tasks is
6 Cognitive-Behavioral Therapy for Generalized Anxiety Disorder: Case Formulation and… 77

preventing her from being promoted. She decides [21], one important direction for future research
to make a list of tasks to delegate each week and is to develop tools to assist clinicians in personal-
to spend Monday morning assigning these tasks izing CBT. The results of one open trial indicate
to paralegals. Finally, she realizes that she has that CBT for GAD can be made more efficient by
been ignoring the domain of self-care because personalizing the number and order of treatment
she feels uncomfortable taking time for herself. strategies based on idiographic symptom models
She decides to begin by walking outside for [52]. However, more research is needed to develop
10 min each day during her lunch break. user-friendly methods for personalizing treatment
plans in applied clinical settings. Evidence-based
methods for increasing access to CBT for GAD are
Session 12 also needed. Digital CBT programs appear effica-
cious for GAD and could help reduce barriers to
Session 12 is the final session, so the therapist care for those with the disorder [53].
re-administers the self-report scales. Elena’s
GAD-7 score dropped to an 8 (mild GAD) and
her PSWQ-PW score dropped to a 42. Elena is Suggested Resources
happy to see that her scores are lower and reports
that she feels her anxiety has improved. The ther- Books and Manuals
apist and Elena also reflect on her treatment • Zinbarg RE, Craske MG, Barlow DH. Mastery
goals. Elena observes that she met all three of her of your anxiety and worry: Therapist Guide
goals, as she now has tools to interrupt worry (Second Edition). New York, NY: Oxford
loops at work, is sleeping an average of 7 h a University Press; 2006. [54].
night and is getting along much better with her • Craske MG, Barlow DH. Mastery of your
husband. However, she tells the therapist that she anxiety and worry: Workbook (Second
worries her anxiety will increase again during Edition). New York, NY: Oxford University
more stressful periods at work. They discuss Press; 2006. [55].
ways that Elena can maintain her CBT skills • Barlow DH, Farchione TJ, Sauer-Zavala S,
practice as well as the need for extra skills prac- Murray Latin H, Ellard KK, Bullis JR, et al.
tice during periods of heightened stress. The ther- Unified protocol for transdiagnostic treatment
apist also offers Elena the option of completing of emotional disorders: therapist guide
CBT booster sessions in the future if she is hav- (Second Edition). New York, NY: Oxford
ing difficulty managing a period of high stress. University Press; 2018. [42].
• Barlow DH, Sauer-Zavala S, Farchione TJ,
Murray Latin H, Ellard KK, Bullis JR, et al.
Summary and Future Directions Unified protocol for transdiagnostic treatment
of emotional disorders: patient workbook
CBT is a well-studied, efficacious treatment for (Second Edition). New York, NY: Oxford
GAD that emerged from cognitive-behavioral University Press; 2018. [56].
models of the disorder. These models propose • Orsillo SM, Roemer L. The mindful way
that chronic worry in GAD serves as an ineffec- through anxiety. New York, NY: The Guilford
tive emotion regulation strategy that individuals Press; 2011. [50].
use to cope with uncomfortable emotions.
Treatment therefore involves teaching patients to
recognize and accept their emotions and to utilize Professional Organizations
more effective emotion regulation strategies • Anxiety and Depression Association of
when negative emotions arise. America: https://adaa.org
Given the heterogeneity of symptom profiles and • Association for Behavioral and Cognitive
symptom dynamics among individuals with GAD Therapies: https://www.abct.org/Home/